This week might be a good time to review some Health Insurance 101 Basics for our readers. Let’s start with some common terms:
Deductible – the dollar amount an insured individual must pay for covered expenses during a calendar year before the plan begins paying co-insurance or its share of benefits.
Co-pay/co-payment – the amount an insured individual must pay toward the cost of a particular benefit. For example, a plan might require a $25 co-pay for each doctor’s office visit. This may or may not apply to the deductible. Read the fine print!
Co-insurance – the percentage of covered expenses an insured individual shares with the carrier. (i.e., for an 80/20 plan, the health plan member’s co-insurance is 20%.) If applicable, co-insurance applies after the insured pays the deductible and is only required up to the plan’s stop loss amount. The ACA simplified plans and most of the coinsurance amounts go toward the Stop-loss our out of pocket maximum.
Stop-loss – the dollar amount of claims filed for eligible expenses at which the insurance begins to pay at 100% per insured individual. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance. When comparing plan choices, it’s important to look at this number. Actuaries are mathematicians who set rates for insurance companies. If you add up the premium you will pay, plus the out of pocket maximum on different plans, you will often see them to be surprisingly close.
How do I find a PPO doctor in my health plan?
Preferred Provider Plans (PPO) means simply that you received the highest level of benefits or lowest share of cost out of your pocket if you use a preferred provider. An Exclusive Provider Plan (EPO) plan means that you get no benefits if you do not use a network provider. Most health plans have multiple ways for you to find out who is an in-network provider. You may call the customer service number on your card and they can assist you. Be advised, this may require wait time on the phone.
Another option is to use their “find a provider” tool on the website. Just be very careful to choose the right network for your plan. For example, if you have an individual plan (not employer sponsored and not a Medicare Plan) with Anthem in 2018, you are in the Pathway EPO network. This is the same regardless if you are on the Exchange (through Covered CA) or off the Exchange.
It is always a good idea to confirm with your provider before you access services. Since providers change status and the website may not be updated, this gives you additional assurance.
It is important to be aware that you may also contact customer service for an out of network referral if there is not a Preferred Provider within your geographic area. Call the 800 number on your card to begin the process before you receive services such as surgery.
It is quite frustrating that it is so difficult to obtain timely and accurate provider network information. Laws changed last year requiring carriers to keep their sites updated, but it’s always best to err on the side of caution.
Can I refer myself to a specialist?
On a PPO plan you may self-refer to a specialist. If the provider is in the network you will receive the highest level of benefits. But be aware that due to the high patient volume, some specialists may request that you have a referral from a primary care provider to effectively pre-screen your medical situation.
Note: All information in this column is provided” to the best of my knowledge” subject to final regulation by the respective agencies.
