Understanding Insurance benefits
Insurance can be tricky to understand even for the most well versed employees, so you might imagine how some patients feel. Some people are great at understanding their particular plan, however others have a more difficult time understanding.
When coming across an individual who does not understand their benefits, patience is key. Insurance can be frustrating and part of working in the medical field is sharing your expertise! Sure, many say it is the responsibility of the patient to understand their benefits. But it never hurts to have some compassion and understanding when it comes to such a confusing topic.
BASIC Insurance VOCAB:
Copay: A fixed amount you pay for a covered healthcare service
Coinsurance: The patient’s share of the cost of covered healthcare services. Coinsurance percentage begins after the full deductible is met.
Deductible: The amount owed for covered healthcare services before your insurance begins to pay (this may not apply to all services)
Out of pocket limit: The most you pay during a policy period before your insurance begins paying 100% of covered services.
Allowed (contractual) amount: The maximum amount payment for covered health services
Billed amount: The amount billed to insurance (not necessarily what will be paid/due). Practices have to bill out an amount to cover all insurance contracts so the billed amount may seem high, but that is not what is allowed by the insurance (see allowed amount).
CMS has a great glossary of health coverage and medical terms which we have linked here.
There are many plans available and it’s difficult to understand them all. Below are a list of a few types of plans:
HMO (Health Maintenance Organization): Usually more budget friendly and requires you to use a specific HMO network and obtain a referral from your primary doctor prior to seeing a specialist.
POS (Point of Service): Like an HMO, a POS plan may require you to obtain a referral before seeing a specialist. The difference is a slightly higher premium and the coverage of out-of-network physicians.
EPO (Exclusive Provider Organization): EPO’s only cover in-network care and are generally larger networks. They may or may not require referrals. Premiums are typically higher than HMOs but lower than PPOs.
PPO (Preferred Provider Organization): These plans have a higher premium but allows you to see specialists and out-of-network doctor’s without a referral.
HDHP w/ HSA (High Deductible Health Plan with Health Savings Account): These plans have low premiums but high upfront costs. With the HSA, you can deposit pre-tax dollars into your account to cover medical expenses. Many times, well visits and certain tests are covered at 100% based on age.
Offices can provide handouts and educational material for patients to help them in understanding their benefits. And when confronted with a patient who lacks insurance knowledge, try to put yourself in their shoes. Remember what it is like to not understand something how you would want someone to explain it to you.
Resources:
https://www.aetna.com/health-guide/hmo-pos-ppo-hdhp-whats-the-difference.html
https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/uniform-glossary-final.pdf
