It’s no surprise that the dynamics of the healthcare industry are shifting considerably. This is the primary topic that I have been drowning myself in since my first day here at FBinsure. Healthcare, P.A.C.A, Obama-care, A.C.A or whatever title that headlines of newspapers, blogs and broadcast news all around the nation call it. Whatever you want to call it, it is a controversial yet a confusing topic. We in Massachusetts have been lucky in a sense since we have been required to have coverage for a few years now. Those that are reading this may be thinking, “How does all this healthcare noise impact me?” After attending the major carrier trainings for brokers in our state for the fourth quarter, I have noticed one major change this reform is providing; it’s plan transparency. This is not a huge win for many folks out there, unfortunately, but overall Healthcare Reform does shine some light on a matter that can be confusing to the masses.
Primarily, the law requires all healthcare providers to have a consistent outline pertaining to the summary of benefits. This transparency of carrier health plans allows the opportunity for the average person not only to understand their coverage, but to be proactive toward their healthcare coverage. After all, we are all consumers and when it comes to healthcare it’s important to know where we receive our healthcare from and whether or not it will cost us more money out of pocket. It’s not every day someone comes home from work and decides to review their healthcare plan summary, but you should be aware of the minor changes in your health plan. Just a disclaimer, if you or your employer use a broker please reach out to him/her as they can explain the key points in your healthcare plan.
There are many things to learn when navigating through all the changes in healthcare today, but being proactive and knowing what will impact yourself as an individual or your family should be of the utmost importance. The first place to start is sitting down and looking at your current health plan and reading your plan summary. Your plan summary is the area where you will truly learn about your coverage and where you will find what all of your out of pocket expenses will be within the plan year. This will primarily be your co-pays for doctor visits, specialist visits, prescriptions, emergency room visits, etc.
The one that most tend to forget is called “Out-of-pocket maximum”, this can vary by plan. The yearly out-of-pocket maximum is the highest total amount your health insurance company requires you to pay towards the cost of your health care. Out-of-pocket expenses are what you pay for health-related services above and beyond your monthly premium. Depending on your health plan, these expenses may include an annual deductible, co-insurance, copayments for doctor visits and prescription drugs. The out-of-pocket maximum helps protect you from very high additional costs. In most cases, once you reach your health plan’s out-of-pocket maximum, your insurance company will cover 100% of the costs they consider to be medically necessary. Some health plans do not count all of your out-of-pocket expenses when determining the “out of pocket” maximum. For example, your plan may not include your annual deductible and some plans may not include the co-pays associated with outpatient procedures. Co-insurance is another item that may sneak up on you if it is part of your health plan, especially if you have to be in the hospital for anything or have high healthcare expenses. Co-insurance is explained on healthcare.gov as “Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service.” You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. This is just something that every consumer should be aware of. I only say this because co-insurance and their deductible alone could set anyone behind financially. For example, someone can pay for their full deductable and then get another bill in the mail for the remainder of the cost due to co-insurance costs.
This blog certainly won’t be the end all be all in helping you make better decisions and choices, however, it is a good start in an arena that is at best confusing and frustrating at the present time. If you have additional questions about health insurance, I always welcome you to give me a call at the office at 1-800-734-6604 or stopping by the office at 128 Dean Street in Taunton.
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