Health Insurance 101

Health Insurance 101: The Good, The Bad & The Misunderstood

Health Insurance 101

Thinking about health insurance can seem overwhelming. Different companies all with different policies that offer different coverage. So where do you even begin? This article is health insurance 101. Learn the different parts of health insurance policies and how they relate to you. You will also learn which types of plans are most advantageous and how to choose the right plan.

Deductible, Coinsurance, Copayment, And Out Of Pocket Maximum

Let’s start by looking at the different parts of a health insurance policy. Typically an insurance policy will have a deductible, coinsurance or copayment, and an out-of-pocket maximum. Every insurance plan is different and some may not have every one of these. It’s important for you to understand how each part works, especially when you need to choose a new plan.

Deductible

A deductible is the amount you owe for health care services before your health insurance plan begins to pay.  

  • For example, if Dwayne Johnson’s deductible is $2,000, he must pay the first $2000 himself.
  • After he pays his deductible, he may have to pay a coinsurance or copayment. The insurance company pays the remainder of the amount owed to the provider.
  • In some instances, there is no coinsurance or copayment after the deductible is met. The insurance company pays the full amount.

The deductible may not apply to all health care services that you need. You might not have to pay your deductible for things like physical therapy or chiropractor visits. In these cases, the insurance company will pay some or all of the bill entirely.

Family health insurance plans often have a family deductible, which applies to all family members as a whole.

Coinsurance

A coinsurance is a percentage of the costs for health care services you are responsible for paying after you’ve met your deductible.

  • For example, if the health insurance plan’s allowed amount for an office visit is $100 and Dwayne has met his deductible already, his 20% co-insurance payment would end up being $20.
  • The health insurance company will pay the rest of the allowed amount ($80). 

Coinsurance amounts can be different depending on the type of service. There may be 10% coinsurance for chiropractic visits and a 20% coinsurance for exam visits. Some services may not require a coinsurance at all.

Copayment

A copayment (or copay) is a dollar amount you pay for health care services. Copays are due after you’ve paid your deductible.

  • For example, Dwayne’s health insurance plan’s cost for a doctor’s visit is $100. His particular plan has a copayment charge of $15 for office visits.
  • If Dwayne has already met his deductible, then he will only be responsible for paying $15 at the time of service.
  • If he hasn’t met his deductible, however, he will pay $100, the full allowable amount for the visit.

Most plans have some sort of copay for one or more services. Each service has a different copay. You may have a $30 copay for specialist visits, but a $50 copay for lab tests. Some services may not require a copay at all.

Out Of Pocket Max 

The out-of-pocket maximum (OOPM) is the most you will ever have to pay during a policy period for health care services. Your deductible, coinsurance, and copays go toward your OOPM. Once you have met this amount, the insurance company will pay 100% of all remaining covered services for that year. 

  • For example- Dwayne has a health insurance plan with a $2000 deductible, 20% coinsurance, and $3000 out-of-pocket maximum and he needs a $10,000 surgery…
  • First, he will pay $2000 toward his deductible, leaving $8,000 remaining in medical costs. Now that he has met his deductible for the year, he will no longer have to make deductible payments.
  • Next, he will have to pay his coinsurance. His 20% coinsurance on the remaining costs ($8,000) comes to $1600.
  • His deductible, $2000, plus his coinsurance, $1600, would make his total costs for his surgery $3600.

But, wait? I thought his out-of-pocket maximum was $3,000 and he should never have to pay more than that? 

  • Since his out-of-pocket maximum is $3000, he will only have to pay $3000 for the surgery. His insurance company will pay for the rest of the costs.
  • His insurance company will pay for any covered care he gets for the rest of the plan year as well.

The out-of-pocket limit does not include your monthly premiums. Think of your premium like paying for a gym membership. You pay $29.99 a month to use the gym. Your premium is the monthly payments you make each month to your insurance company to have healthcare coverage. 

The Truth About Patient Payments

When you purchase health insurance, you are under contract with your insurance company.  The insurance company decides how much money you owe. Healthcare providers are never in charge of this.  

A common misconception is that when you are responsible for a payment to a healthcare provider, the provider is getting paid a large sum from the insurance company on top of the amount you’re responsible for paying. In fact, it’s the complete opposite. 

The Big Misconception

If you don’t pay your copay, coinsurance, or deductible, then the doctor who took care of you doesn’t get paid for those services. 

Imagine this: You wake up in extreme back pain, unable to go to work or even get out of bed. Days go by, still unable to work. It starts to take a toll on you; physically, emotionally, and financially. You start worrying that the pain won’t go away. You start worrying that you may have to miss out on important events, like seeing your family.

Finally, you call your doctor in a panic and get a referral for physical therapy. Luckily, you’re able to schedule a physical therapy appointment that day. The therapist gives you a thorough evaluation. They perform tests and are able to give you the care and relief you need. You schedule a few follow-up appointments to continue on your road to recovery. You feel like you’re getting better after each visit.

After a few weeks, you’re starting to feel good as new. You have returned to work, and spent quality time with your family when they came to visit. You feel like you again. Suddenly you get a bill in the mail from your evaluation for $98. You decide you don’t want to “waste” $98. That appointment definitely wasn’t worth $98 and the office is crazy for thinking that way. You ignore the bill and use that $98 for something “more important”.

The Truth About Patient Responsibilities

A few weeks ago when you were stuck in bed and unable to work, you didn’t think anything was “more important” than your health and feeling better. Choosing not to pay your doctor means you aren’t making your health a priority. By not making that payment, you’re taking advantage of your own self-worth.

You’re taking advantage of the physical therapist too.

They aren’t getting the respect or compensation they deserve. Think about the time your therapist spent trying to find the cause of your pain. The physical work they put into soothing your sore muscles so you could enjoy playing with your nieces and nephews. The emotional investment they put into your well-being each and every day, even on the days away from the clinic. 

Explanation Of Benefits

Your payment makes up the majority, if not the entirety, of the payment your provider receives. Remember that next time you get a bill in the mail.

The total reimbursement a provider gets = insurance company payments + patient payments. The reimbursement is a predetermined, set amount based on the services that are performed. The set price doesn’t change. The amount the insurance company will pay and the amount the patient is responsible for paying can change. 

Sometimes the insurance company is responsible for paying way less than the patient, or vice versa. In the cases where patients meet their OOPM, the insurance company is responsible for paying entirely. The patient is not responsible for making any payments.

  • For instance, your Explanation Of Benefits says you owe your healthcare provider $11.55 as your coinsurance charge, while the insurance company owes them $89.45.
  • But if your Explanation Of Benefits states that you owe a $45 copay on a $70 charge and you decide not to pay, the provider is only going to receive the $25 payment from your insurance company for the care they gave you

Choosing A Plan

Now that you understand the parts of a health insurance plan, we will focus on how to choose the best plan for you and your family.  Although this can feel complicated, breaking it down into two main areas will help make the decision-making process. The two areas to consider when choosing a new health insurance plan are your total costs and the plan/network types.

Your total costs include your monthly premium payments, as well as any out-of-pocket costs, such as a deductible, coinsurance, or copay. You still pay your monthly premium to your insurance company even if you don’t see a doctor. It’s important to factor in these costs when choosing a new health insurance plan.

Beware Of Low-Cost Plans; You Get What You Pay For

The old saying is true, you get what you pay for. When choosing a new healthcare plan, a good rule of thumb is as follows: 

Plans with ↓ lower monthly premiums generally have ↑ higher deductibles. 

Plans with ↑ higher monthly premiums usually have ↓ lower deductibles. 

The same applies to your OOPM.
Plans with ↓ lower monthly premiums typically have ↑ higher out of pocket maximums. 

Plans with ↑ higher monthly premiums usually have ↓ lower out of pocket maximums. 

A Closer Look

Let’s dive a bit deeper into this concept. If you’re a healthy person who doesn’t go to the doctor often, you’re going to want to pay as little as possible each month for healthcare coverage. Why pay a ton for services you’re barely going to use?  

When it does come time to get medical services, typically you’re going to have a large deductible to meet, as well as more out-of-pocket costs. Because you’re essentially “saving money” by paying less on your monthly premiums, you’ll have to spend more if and when you actually use your insurance.

Now let’s take a look at the opposite scenario; you have a chronic medical condition that requires you to go to the doctor regularly. Since you know that you are going to be receiving a lot of medical care throughout the year, you decide to pay a higher monthly premium to have an insurance plan with a lower deductible. 

Look At Your Budget

Choosing a plan with a higher monthly premium gives you the ability to predict your costs. This allows you to fit those costs into your budget. You’re prepared to pay the monthly premium amount and know that you won’t have to pay much to meet your deductible. You shouldn’t have many surprise medical bills because of this.

Since higher premium plans tend to have both lower deductibles and OOPM, you’ll end up meeting your OOPM quicker too. This means your insurance company will start covering your costs quicker as a result. 

Choosing Your Plan

When it comes to plan and network types, you’re looking at the type of health care services that are covered in your plan. As well as the doctors and facilities you are allowed to see. Some plan types let you see any doctor at any health care facility. Other plans can limit your choices or charge you more if you use providers outside of the insurance company’s network. 

The different plan types include HMOs, PPOs, POSs and EPOs. Each plan type has a different amount of freedom for choosing healthcare providers.

Health Maintenance Organizations (HMOs)

A type of health insurance plan that usually limits you to see doctors who are contracted with the HMO network. This plan generally doesn’t cover out-of-network services, except in the case of an emergency. An HMO also requires you to choose a primary care physician to be eligible for coverage. The primary care physician helps coordinate your care. This means they must give you permission before seeing a specialist.

Preferred Provider Organizations (PPOs)

A type of health insurance plan that contracts providers to create a group of ‘participating providers.’ If you see a doctor that is considered a ‘participating provider,’ you will pay less than you would for a doctor who isn’t. You can still see doctors outside of that plan’s network, but you will have to pay more for those services.

Point Of Services (POSs)

A type of health insurance plan where you pay less if you use doctors, hospitals and other health care providers that belong to the plan’s network. Think of a POS plan as a hybrid between an HMO and PPO. You are choosing whether you want to use HMO or PPO services each time you go to the doctor. Like an HMO plan, you have to choose a primary care physician, but you can pay extra to see non-participating providers, as you would with a PPO plan. POS plans also require you to get a referral from your primary care physician if you need to see a specialist for any reason.

Exclusive Provider Organizations (EPOs)

A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network, except in an emergency. Unlike an HMO, you don’t need to name a primary care physician or get a referral to see a specialist, as long as you choose a ‘participating provider.’

A network provider has agreed to provide services to the plan’s members at a discounted price.

If you use an out-of-network provider, you may have to pay the full cost, regardless of which plan type you have, except for emergency services. If you get emergency services from an out-of-network provider, those services are covered by a Marketplace plan as if you used an in-network provider. However, providers may bill you for some additional costs for the emergency services.

Make A List

When choosing health insurance plans, start by making a list of all the health care providers you see. That includes healthcare providers like doctors, psychologists, or physical therapists. Also any healthcare facilities like hospitals, urgent care clinics, or pharmacies as well. 

Insurance companies may have different networks for different plan types. Make sure you’re searching the provider network of each specific plan you’re looking into. For instance, your primary care physician may be in-network with the Blue Cross Blue Shield PPO plan you’re looking into, but out-of-network for Blue Cross’s HMO plan. The best way to check if your providers are in-network with each plan is to call the health insurance company.

Supplemental & Replacement Coverage

Some people decide to get additional health insurance coverage. This comes in the form of a secondary health insurance plan. Secondary insurance, also called supplemental insurance, is coverage that fills in gaps of the primary health insurance plan. this can include copayments, coinsurances, and deductibles. 

Secondary health insurance plans are meant to work with primary health insurance plans, not replace them. 

  • For example: Dwayne Johnson’s primary insurance is Aetna, which only covers 80% of his medical expenses.
  • Dwayne decided to purchase a secondary insurance plan through Blue Cross Blue Shield, which picks up the remaining 20% that his Aetna policy does not cover.
  • Although Dwayne has to pay a monthly premium in order to have secondary coverage from Blue Cross Blue Shield, the cost of that premium tends to be a lot lower than the out-of-pocket medical costs he would have to pay with Aetna coverage alone. 

Medicare Options

When it comes to additional coverage, those who qualify for Medicare health insurance have a few different options. A person can purchase a secondary insurance plan, often referred to in this case as ‘Medigap’. These plans cover some or all of the expenses Medicare does not.

Another option is a replacement insurance plan. Medicare replacement plans are just that- replacement plans for standard Medicare health insurance. A person can purchase a replacement plan through a private insurance company, such as Blue Cross Blue Shield, that typically covers everything that traditional Medicare would, but also covers additional services as well.

Replacement Plans

These replacement plans, called ‘Medicare Advantage Plans’, are similar to private health insurance plans in both cost and coverage. Advantage Plans can have deductibles, coinsurances, and copayments, depending on the service. Some plans offer out-of-network benefits and some only cover healthcare providers that are in their network.

These plans were created to lower costs and improve the quality of care given. They also were meant to give patients more choices. Unfortunately, changes over the years have strayed from those original goals. Many replacement plans can actually cost more, through premiums and out-of-pocket costs, than costs with traditional Medicare alone would. Advantage plans also have their own provider networks that may restrict the doctors you are able to go to.

  • For example, Dwayne is enrolled with Medicare for his health insurance but decides to purchase a Medicare replacement plan through Blue Cross Blue Shield. 
  • He pays less for his Blue Cross Blue Shield Medicare Advantage plan than he would for Medicare as his primary insurance and Blue Cross as his secondary insurance combined, but he is now limited to seeing doctors within his replacement plan’s network. 
  • The family doctor he has been seeing for over 20 years is not in-network with his replacement plan, leaving Dwayne to find a different doctor for him and his family.

It’s extremely beneficial to understand the differences between supplemental and replacement plans. Often times people are under the impression that they have supplemental health insurance when they actually have a replacement plan. 

Seeing Healthcare Providers

It’s especially important to understand and disclose your exact plan type when scheduling appointments with a healthcare provider, as each plan has different coverage, different costs and different limitations. Click here to learn how the billing process works when receiving physical therapy treatment. Indicating that you have Medicare and Blue Cross Blue Shield plans is incredibly different than having a Blue Cross Blue Shield Medicare Advantage plan.

  • For example: Dwayne had surgery to repair a knee injury and needs physical therapy. When scheduling his first visit, Dwayne states that he has Medicare and Blue Cross Blue Shield plans. He schedules all of his appointments ahead of time for an entire plan of care. He is also told that it is very likely that he has met his Medicare deductible for the year since he has already paid for his surgery, therefore it’s expected that he shouldn’t be responsible for any large payments, if any at all. 
  • After the physical therapy clinic looks into his policies, they discover that Dwayne does not have separate Medicare and Blue Cross Blue Shield plans, rather he has a Blue Cross Blue Shield Medicare Advantage plan; a replacement plan. This plan requires pre-authorization in order to even begin physical therapy treatment, a process that could take up to 14 business days to be approved, and is limited in number of visits he’s allowed to have. On top of that, his plan has a $40 copayment for each physical therapy session. Dwayne now has to reschedule and reduce the number of visits he has already scheduled, as well factor some unexpected costs into his budget.

Final Thoughts

Although it may seem complex, understanding the ins and outs of health insurance coverage will be extremely beneficial. You may even start noticing how some insurance companies’ advertisements can be quite misleading to those who aren’t as familiar with health insurance. 

Popular insurance commercials often claim that their plans “have no copays, no deductibles” or things along that same line. These plans may sound appealing, but the money being “saved” has to be balanced out somewhere- whether it’s with charging you high monthly premium payments or significantly limiting the doctors and services that are covered. 

A good rule of thumb is if it seems too good to be true, it probably is. Look further into the eligibility and benefits of the plan to see just how “perfect” the plan really is.

Using your newly acquired knowledge about health insurance plans will allow you to better decide whether those plans are right for you and your family.

Borja PT’s Top Recommended Insurance Picks For 2020

When it comes to physical therapy services, insurance companies such as…

  • Meridian
  • Blue Cross Complete
  • McLaren 
  • United Healthcare Community

generally have State Marketplace plans with physical therapy coverage at little or no cost to the subscriber. 

Likewise, 

tend to have private health care plans with physical therapy coverage at little or no cost to the subscriber as well.

**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.

About The Author

Jaime Curl

I've explored various fields within physical therapy including acute care and oncology at Troy Beaumont Hospital and outpatient physical therapy. As the office administrator and marketer, I'm able to combine my love for health and exercise science with my interest in marketing and numbers skills. My hobbies include spending time with friends and family, baking, crafting, and watching my favorite movies or tv shows.

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