If you’re like most people, you met your health insurance deductible by the time September rolled in. That means your insurance is finally (yay!) paying your medical bills and will continue to for the rest of the year. At this point, most have small aches and pains they think will just go away, and never end up using the physical therapy visits they’re entitled to use. You don’t want to wait until January just to have to pay down your deductible (again). Let’s take a closer look at how to maximize your health insurance before you miss out on the benefits you worked all year for.
What Are Health Insurance Benefits?
The first step to maximizing your health insurance is understanding the different parts that make up your coverage. Insurance plans typically consist of a deductible, copay, coinsurance, and out-of-pocket maximum.
Deductible
A deductible is an amount you must pay before your health insurance starts paying any expenses.
For example, if your deductible is $1000, then you’re solely responsible for any medical bills until you pay the $1000 yourself. After you meet your deductible, insurance will pay for some or all of your medical bills. In some instances, depending on the service, the deductible doesn’t apply and the insurance company covers the entire bill.
Copay
A copay is a set dollar amount you pay for certain healthcare services. Typically, you don’t have to pay copays until you meet your deductible.
Let’s say that a doctor’s visit costs $200 and your plan has a $15 copay for office visits. If you have met your deductible, you’re only responsible for paying the $15 copay. If you haven’t met your deductible, then you’re responsible for the full $200. Most plans have some sort of copay depending on the service, but some don’t require one at all.
Coinsurance
A coinsurance is a percentage of the total cost for certain services that you must pay after your deductible.
Let’s take the example from above where a doctor’s visit costs $200 but instead your plan has a 15% coinsurance. If you’ve met your deductible, you’ll only pay the 15% coinsurance, which is $30. The insurance company pays the remaining $170 of the bill. Similar to deductibles and copays, some services might not require a coinsurance.
Out Of Pocket Maximum (OOPM)
The OOPM is the most you will ever have to pay during a policy period.
Your deductible, copays, and coinsurances all add up to go toward your OOPM. Once you meet this amount, your insurance pays 100% of all covered healthcare services for the rest of the year.
Let’s say your plan has a $2000 deductible, 20% coinsurance with a $3000 OOPM, when suddenly you need a $10,000 surgery. First, you’ll pay your $2000 deductible, leaving $8000 remaining of the bill. Next is your coinsurance. Your 20% coinsurance of the remaining $8000 comes to $1600. With your deductible of $2000 and coinsurance of $1800, your total cost for the surgery is $3600. But wait… your OOPM is $3000, which means you’re only responsible for paying $3000 while your insurance pays for the $7000 balance.
Other Limits
Most insurance plans have limits for certain healthcare services. For example, they might allow 50 physical therapy visits each year. Other times, they might cover up to $300 in emergency room charges or the cost of one new set of orthopedic insoles per year.
What Are The Different Types Of Plans?
When it comes to health insurance, there are different types of plans all with different types of coverage. Most insurance companies, like Blue Cross Blue Shield, offer several options to choose from.
The biggest differences between the plans is the coverage of benefits. In other words, you’re looking at which healthcare services and doctors you’re allowed to go to. Some plans let you see any doctor you want. Others only let you see providers in their particular network, or charge you more to see ones that are out of their network.
The main types of insurance plans include HMO’s, EPO’s, POS’s, and PPO’s.
Health Maintenance Organizations (HMO)
HMO plans only allow you to see providers that are contracted by the HMO network. Typically, there are no out of network benefits with these plans. You also have to choose a primary care physician. They coordinate your care and must give their approval if you want to see a specialist.
Exclusive Provider Organizations (EPO)
EPO plans are similar to HMO plans, where you have to go to doctors, specialists, and facilities contracted by the network. However, you don’t need to get approval to visit a specialist. You just have to choose one that’s participating within the network.
Point Of Services (POS)
With POS plans, you pay less if you choose doctors, hospitals, and other providers that are contracted with the network. You still have to choose a primary care physician to coordinate your care, but can go to non-network providers for an additional charge.
Preferred Provider Organizations (PPO)
PPO plans generally have the most options in terms of coverage. You get both in and out of network benefits, but will pay less if you choose providers participating in the network. They also more coverage for ancillary services, like imaging and lab tests.
Supplemental & Replacement Coverage
Some people choose to get additional insurance coverage, called supplemental or secondary insurance, that works with their primary insurance to fill in any gaps of coverage. This includes things like gaps in deductibles, copays, and coinsurance payments.
For example, if your primary insurance covers 80% of medical expenses, you could purchase a secondary plan that would cover the remaining 20%. Although you do have to pay for a monthly premium for the secondary insurance, depending on how often you go to the doctors, your total overall expenses may be less in the long run.
Medicare Replacement Plans
People that qualify for Medicare insurance have an additional option in the form of a replacement plan. Medicare replacement plans replace your standard Medicare health insurance. You purchase these plans through private insurance companies, like Aetna or BCBS. These plans typically cover what traditional Medicare would, as well as additional services too.
Click here to learn more about the ins and outs of health insurance.
How Do You Know When Insurance Will Pay?
To make the most of your health insurance, you should use it when the insurance company is the one paying. So, how do you know when you’ve hit your deductible and insurance will cover the bills?
Explanation Of Benefits
One way to get this information is from your explanation of benefits. An explanation of benefits (EOB) is a document that’s mailed to you by the insurance company that summarizes your most recent medical visit. More importantly, EOB’s list the charges of each procedure and who is responsible for the bill.
If you’re still working on your deductible, you’re EOB will show a patient responsibility. There will be a detailed breakdown with exactly how much is going towards your deductible. It’ll also say how much of your deductible remains, and list the total amount you’ve paid in medical expenses so far this year. If you’ve already met your deductible, the EOB will show the insurance company covering a portion, if not the entirety, of the bill. That’s when you know it’s time to take maximize your benefits.
Patient Portal
Nowadays, most insurance companies have some sort of patient portal you can log into. It’ll show your progress toward meeting your deductible, as well as how close you are to hitting your OOPM. After you meet your deductible, the insurance company will cover some or all of the costs.
Some portals have a list of services with expandable sections that show further details, like how many physical therapy visits you have remaining for the year. These sections may state that the service doesn’t require a deductible or copay and are covered 100% by insurance. In these cases, you don’t have to wait or worry about meeting your deductible. You can use the visits whether you’ve met it or not.
While having services that don’t require a deductible or copay is great, it’s worth noting that the same insurance plan might not have the exact same benefits when they reset at the beginning of the year. And even if your new plan does have the same coverage, it’s advantageous to use your visits before they’re gone. It really is a “you don’t use it, you lose it” situation.
Using Your Benefits
One of the biggest mistakes people make after meeting their deductible is doing nothing at all. You don’t want to miss your opportunity and essentially end up throwing away your covered benefits.
On average, people lose $1,543 worth of physical therapy benefits each year.
This means insurance subscribers had PT visits available that their insurance would have paid for, but just didn’t use them. Small aches and pains can grow into big problems in a matter of weeks, so it can be extremely advantageous to start PT when you have coverage.
Remember, as soon as the new year hits, your deductible and OOPM reset. So, if your problem continues (or gets worse) you’ll be left with the bill. Don’t wait until it’s too late. Take charge of your aches and pains. Let our team help you feel your best and start the new year off right.
Call our office at (586) 884-4565 to schedule now.
**All statements made by Borja Physical Therapy are generalized statements regarding most health insurance plans and in no way is a guarantee of benefits or eligibility. All statements are based on benefits that are considered covered healthcare services.
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