Are you confused about all the options available for health insurance? Coinsurance, deductibles, maximum out-of-pocket, primary care, specialists… we know this can be confusing, yet understanding these options is critical because they are the basis for premium determination. That’s where we come in. We want to be sure you understand what is available to you and what would be most useful for you and your family.
Deciding on what health insurance options make sense for you and your family can be difficult. How do I determine the best option for my family? What is the difference between co-pays and coinsurance? How do I know what doctor I can see?
David B. Crother is ready to guide you through the complex world of health insurance to determine the best plan to fit you, your family and your lifestyle. Whatever your specific needs, David can find a plan that provides the optimum balance of value and coverage. Contact us for more information at (530) 674-1098.
Aren’t they the same thing? No. A co-pay is a fixed dollar amount that you pay before you meet your deductible when you have an office visit, an urgent care visit, a hospital visit or other health-related doctor’s visit. In the co-pay scheme, a regular office visit will be less than an urgent care visit, which is less than a hospital visit. Co-pay amounts vary depending on your health plan. Co-pays provide a way for the insured to share the cost of health care expenses with the insurance company. They also serve to deter insureds from seeking unnecessary medical treatment for minor ailments that do not really require the help of a medical professional. Coinsurance and co-pays differ in that as mentioned before, a co-pay is a set dollar amount that you pay each time you visit the doctor or fill a prescription. Coinsurance comes into play after you have met your deductible. At this point, you will pay typically 20-30% of the billed and allowed fees until you reach your out-of-pocket maximum as indicated in your policy.
All health insurance plans have what is called an out of pocket maximum. This term can be misleading. This refers to not the total amount of money you will have to pay in a given year, but rather the total amount of money you will have to pay AFTER your deductible and excluding co-pays. Once you have reached your out of pocket maximum for a plan, all health expenses are covered at 100%. (Max out of pocket is usually defined as deductible + coinsurance. Copays continue even after the moop is met)
A Health Management Organization (HMO) is a form of health insurance plans where the patient chooses a primary care physician, from whom all referrals to specialists come from. If, for example, you develop a heart condition, your primary care physician would be the doctor who would refer you to a cardiologist. This cardiologist, most often in the same organization as your primary care physician, cannot see you without this referral.
Preferred Provider Organizations (PPO) are formed when health insurance companies and groups of doctors come to an arrangement on fees. A PPO will work with a doctor group to negotiate lower costs for their insured. This savings is then passed on to the patient in the form of lower health care costs. If you have a health insurance plan that has coinsurance, this plan will ensure that you have the best price for services. In PPOs, there is often not a need to designate a primary care physician who then refers patients to other doctors. Generally, patients are able to make appointments with any doctor within a network on their own.
With both of these systems, you will often see in-network and out of network prices. Insurance companies contract with doctors across the country to offer the best prices for their patients. Often there are doctors who choose not to participate with the insurance companies, or networks of doctors whose fees are too high to be part of the regular insurance plans. In this case, those doctors would be considered out of network, and higher fees would apply to any visits to these doctors.
Many people don’t realize just how affordable dental and vision coverage can be. As with other areas of insurance, there are many different options available to you. Contact us today, we would love to have the opportunity to talk with you about your specific needs.
“Working with David and Kathy makes my job easier! Our employees trust them to the fullest extent with their health care. We couldn’t ask for a more professional team.”