New Year, New Insurance

Be sure to know what is covered

January 14, 2016


With the new year, often comes new health insurance cards. This is the time of year that many health insurance plans offered by companies to employees change.

At Penn Highlands Healthcare, we never want our patients to feel that money comes before care. We also want our patients to understand what their insurance covers and doesn’t.  We would like all of your surprises in life to be good ones.

As you go into the new year, make sure your insurance – even if it is the same company as before – didn’t change what it is covering for you, according to Jocelyn Long, RN, of Penn Highlands DuBois. Long is working with a committee to encourage patients to avoid stress and ask important questions.

Ask your insurance company, “Does my insurance pay for this?” if you are scheduled for a test or procedure, she said.

Insurance companies use medical guidelines to determine how often you should undergo a particular test. It may be yearly or every five years. Check with your insurance first to be sure its rules did not change.

Screenings are valuable tools. They can be performed as part of your yearly preventative healthcare.  But keep in mind an insurance company may offer it once within the calendar year or expect it to be a year from the last one. If it’s the latter, then having a screening again in August instead of September may be too soon to be covered.

Also, if the screening leads to a diagnosis of a disease, such of diabetes, or a condition, such as high cholesterol, screenings are no longer necessary. Tests ordered should monitor your condition and coverage amounts can change.

Always review your deductible, co-pay and coinsurance information. Those terms are used in the insurance world. The common bond each has is it reflects the amount of money you may pay out-of-pocket (i.e.: the amount not covered by insurance) for healthcare services but each term is distinct. 

To help, the Human Resources Department at Penn Highlands Healthcare has shared definitions and illustrations of how each is applied:

Co-Pay: A fixed fee that you pay for specific services covered by the health plan. Medical plans typically have three types of co-pays: Primary Care Physician Office Visits, Specialist Office Visits and Emergency Room Visits. Insurance covers the balance after a flat amount is paid such as $20 for office visits or $50 for emergency room visits, depending on your plan. Annual routine physical exams are considered preventive care and are covered 100 percent by insurance, so no co-pay applies.

Deductible: The amount you pay each year before benefits begin. In general, deductibles apply to most services with few exceptions and it accumulates over the course of the year. Once deductibles are paid, insurance begins to pay benefits. Deductibles are not the same as co-pays. Co-pays are separate and are not applied to your deductible. The deductible does not apply to office visits or Emergency Department visits, which are covered after co-pays, or preventive services, which are covered 100 percent.

Coinsurance: The sharing of costs after a deductible is paid. Some insurances split the cost with you. For example, a common sharing percentage is 90/10. This means the insurance company pays 90 percent of the cost after the deductible is paid and the patient pays 10 percent. 

“Out-of-pocket maximum” are also listed on some insurances. This is the maximum amount you pay of the 10 percent coinsurance before insurance begins to cover 100 percent. For example, suppose you had surgery and you have a $500 individual deductible and 90/10 coinsurance with a $2,000 out-of-pocket maximum. This means you would first pay the $500 deductible. Then, you would pay 10 percent out-of-pocket up to $2,000. Therefore, the cost you would pay for this before insurance covers 100 percent is $2,500. 

Does your insurance have Network and Out-Of-Network coverage differences? 
What is a network? It’s a group of doctors, hospitals and other health care providers that contract with an insurance company and accept your insurance’s lower negotiated payments per the contract. You receive more coverage when you receive services from a participating Network provider. Each insurance company’s Network varies. To determine if a doctor, hospital or health care provider is part of the Network you may ask the provider if they accept your insurance coverage or you may search online if the company has a website or you can all your insurance company directly. 

Out-Of-Network means that doctors, hospitals or other health care providers do not contract with an insurance plan. In other words, the provider does not accept your insurance coverage and you will pay more for the services.

This year, Penn Highlands Healthcare is asking patients to review their information with their physician whenever a test or procedure is being offered. A form will be presented for the patient to sign to acknowledge that he knows he is accepting financial responsibility for a test or procedure.

“We want patients to know what their insurances pay for and what it doesn’t,” Long said. “Together, with their physician, they can make informed decisions about why a test or procedure is done and, perhaps, what the other options may be.”