Understand your health insurance costs before you head to the pediatrician 20 times this year!
With healthcare changing all the time, we can never be too sure about what’s going to happen. The only thing you really have control over is your ability to be in the know and understand your individual health insurance plan.
Don’t be that patient that is completely blindsided when the doctor’s office asks for your payment upon checkout. It’s okay, I’ve totally been that patient too.
There is absolutely nothing worse than finding out you owe a gigantic sum of money to the doctor that you didn’t budget for.
When the front desk asks for your payment, or you get a huge bill in the mail, you might be thinking…
- But I have insurance!
- What’s a deductible?
- What’s co insurance?
- My co pay is only $25, I thought that’s all I have to pay?
These are common things that we hear at our office. I can TOTALLY relate. Just because I’m a doctor, doesn’t mean I understand everything about insurance. I sure as heck don’t.
Even during my residency, the hospital I worked for provided a great insurance plan that covered basically everything. It wasn’t until I had to start looking into health insurance plans of my own that I really understood how dang expensive healthcare is!
Like anything, health insurance is much more complicated than this, but knowing these 5 terms before you go to the doctor can prevent a surprise at check out.
In-Network vs. Out-of-Network
I literally used to think this meant that the doctor’s office was either close by or far away. Ha! It does not.
Doctors have contracts with insurance companies to help lower costs of healthcare. It’s basically an agreement to accept a discounted rate for people included on that plan. This is why you want to find a doctor that is IN NETWORK, so you can keep your costs as low as possible.
It can take doctors several months to get contracted with an insurance plan, and sometimes plans are full and will not accept any more physicians. This may be why your doctor doesn’t accept a certain insurance, so always check with your doctor before switching your plan. The whole “you can keep your doctor” thing only works if your doctor is on your plan. Otherwise, you will have to pay much more to see them.
Similar to when you get in a car accident, the deductible is what you will be responsible for before your insurance kicks in.
If you have a $1,000 dollar deductible and your bill is $250 and you haven’t met your deductible, you will be expected to pay in full for that visit. This is something you should definitely pay attention to when choosing a plan. Usually a high deductible plan will have a lower monthly premium (payment) and vice versa.
Your co-pay is your portion of the doctor visit that you are expected to pay. This is something that you agree upon when you sign a contract with your insurance provider. If the total office visit rate is $125, and your co-pay is $25, the insurance will pay $100 with the assumption that you already paid your portion at the time of service.
This is usually one that comes as a surprise to people. Your insurance plan may require a co-insurance. This kicks in once you have met your deductible. Let’s stick with the example that the visit cost is $125. You have met your deductible and paid your $25 co-pay. Well, your specific plan now requires a co-insurance of 20% in addition to your co-pay. For that visit, the insurance will pay $80, assuming you will pay the $20 co-insurance and $25 co-pay.
Max Out of Pocket
Now you are probably thinking…”Okay, so I have to pay $1000 deductible, and co-insurance, and co-pays?! When does it end?! Can you make it stop?”
Unfortunately, no. BUT, once you hit your max out of pocket, everything will finally be covered at 100%. This number can be extremely high, but it’s always good to know. If you never reach your max out of pocket, that probably means that you and your family are healthy, so yay!
These examples assume that there aren’t any fun things like claim denials, billing errors, and coverage changes, which make your doctor want to pull their hair out just as much as you!
Hopefully this will help you understand your health coverage a little better, before cold and flu season hits, or before you have to select a new plan.
As always, let me know if you have questions! I love to help other moms learn as much as they can to make the best financial decisions for their families.