Understanding Your Medical Insurance | Atlanta ENT Institute
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Understanding Your Medical Insurance

Co-Author: Roni Elder 

“What does deductible mean?!” 

“What’s in-network and out-of-network?” 

“Someone help!” 

Been there? Done that? We have too. 

One of the greatest benefits and perks of your employment are the benefits that come with it.  One of the criteria for choosing a new company or job is what healthcare benefits and out of pocket costs are offered. But do you really understand how insurance works and what’s covered/not covered with health insurance companies? Unfortunately, many people go into doctors appointments and in-office procedures and surgeries thinking that they’re covered, but are surprised when they receive a bill. Understanding your medical insurance is what we’re here to help you do. 

medical bills

Health Insurance can be very confusing. Many times your health insurance providers are not going to be transparent on what the particular responsibilities are of the patient. The less their customers know, the better for the Insurance company. The insurance providers will tell you that they will not have any financial responsibility until the claim is submitted and processed. How is that not frustrating? Trust us, we understand. 

Because of this, the Ear, Nose, and Throat Institute wants you to know and understand that we are not required to abide by the state mandate on estimated balance billing for commercial plans and that we abide by our own policies. It’s also important to understand that all benefits are an estimated quote and are subject to change after the claim is processed by the insurance company in accordance with policy specifics. 

To help you in understanding your medical insurance, click here to learn about the insurances that the ENT Institute currently takes: Patient Information

Insurance can be incredibly confusing, even for us, so here are a few terms we wanted to define and detail with you to make the situation less murky: 

 

Covered Benefit

Covered Person – Any person covered under the plan. 

 

Covered Service

A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan and contracted rates between insurance and network providers.  

 

Understanding Your Medical Insurance Deductibles

This is the amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Based on policy specifics and in and out-of-network benefits.

Coinsurance Percentage

The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible. Let’s say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%. If you’ve paid your deductible, you pay 20% of $100. 

Just because the deductible is met, most plans will have shifted to a coinsurance plan of the following percentages: 

90/10

80/20

70/30

60/40

50/50

The first number is the insurance percentage(60/40), the second number is the patient’s responsibility(10%, 20%, 30%, 40%, 50%). 

These percentages are used to meet the Yearly Out-of-Pocket Max for the patient’s plan. Just because a patient meets their deductible and OOP max Dec 23rd, most plans roll over every year. Meaning, the deductible and OOP amounts start over as of Jan 1. The benefits will be different and they will have an out-of-pocket amount to pay. 

 

Out-of-Pocket Max (OOP)

This is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn’t include your monthly premiums. 

Copays

A copayment (or “copay”) is a monetary charge that your health insurance plan may require you to pay in order to receive a specific medical service or supply. For example, your health insurance plan may require a $15 copayment for an office visit or brand-name prescription drug (and isn’t always applicable to certain tests). 

Prior Authorization

Prior authorization (PA) is a requirement that your physician obtains approval from your health insurance plan to prescribe a specific medication for you. PA is a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company.

 

Referrals

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. 

medical insurance out of network

In and Out-of-Network

A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” (Please note that just because a patient has a referral, it does not guarantee there will be no out-of-pocket costs to the patient. It simply ensures in-network benefits to be applied). 

Allowed Amounts

The allowed amount is the maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If a provider charges more than the plan’s allowed amount, beneficiaries may have to pay the difference. 

 

Contracted Fee Schedule

A set of fees agreed upon by the physician and the carrier. With discounted fee-for-service reimbursement, who do contract fee schedule rates apply to? Managed care enrollees who visit an in-network physician. The contracted fee schedules are all different based upon the individual contracts between carrier and provider. These fees are not readily available to patients but are used to figure the patient’s out-of-pocket amounts. Each fee schedule is different; therefore, will only apply after treatment is agreed upon. The only transparent fee schedule that would be applicable would be out self-pay fee schedule, which is a reduced fee schedule and charging the patients that fee schedule would negate contractual fee schedule agreed upon between carrier and physician. 

Most insurance companies provide a Member Services phone number specifically for members to contact the insurance for questions. That number is located on the back of the insurance card. 

Patients will need to verify the following information: 

  • Policy number
  • Date of birth
  • Zipcode
  • Mailing address

The customer service representative will answer questions to help you in understanding your medical insurance and what any out-of-pocket costs some medical visits, testing, and treatments may result in. These departments are there for you to contact with questions like: 

  • What is my deductible? 
  • How much is met?
  • I have a referral to an ENT specialist, how will my plan cover the office visit? 
  • Are they in or out-of-network? 
  • Do I have out-of-network benefits? 
  • What will my estimated out of pocket be once the claim is processed? 

It’s important to remember that our billing department at the Ear, Nose, and Throat Institute will be happy to educate you on any billing-related questions or concerns you might have. Call 770-740-1860 to inquire about billing, transparent pricing, and any other patient information. It can be a complicated issue, so we hope this information has helped you in understanding your medical insurance better. 

What Insurance Does the ENT Institute Take?

AARP Supplement Accordia Amerigroup
Assurant Care Improvement Campus/Tricare
Cigna Medicare Cincinnati Life First Health
CCN Coventry Medicare Core Source
Echo Evercare (UHC Medicare) GBHS Employees
Fiserv Fortis Group Administrators
Golden Rule (UHC) Great West (part of Cigna) Mamsi
Humana Wellstar Lumenos Mega LIfe/PHCS
Medicare MediPlus Peach State (Medicaid)
Caresource Multiplan Definity
Mutual of Omaha NYS HIP Tricare (Humana Military)
Ambetter from Peach State Peach Care Performax
Allwell from Peach State Smith Administrators South Care
State Health Time Insurance Tricare (Humana Military)
Tricare for Life Tricare (Humana Military) Unicare
Tricare (Humana Military) Tricare Prime Tricare Select
United Healthcare/ UHC Chip plan (medicaid plan) UHC Navigate
Tricare Reserve Select UMR Wausau Benefits
Provider PLAN
Aetna HMO, PPO, POS, EPO, & Promina – Not Par: Emory Choice
Aetna Aexcel Not a preferred Provider for 2014 Aexcel (higher co-pay/ deductibles applies)
Beechstreet PPO
BCBS/Blue Choice HMO, PPO, POS, Indemnity, Medicare, Direct, EPO, Anthem
Cigna HMO, PPO, POS, Medicare, Health Spring, NOT PAR: Local Plus
Coventry HMO, PPO, POS
Group Resources PPO
Guardian PPO
Health Star PPO
PROVIDER PLAN
Humana & Humana Military (Tricare) HMO, PPO, POS, Gold
Humana Gold Medicare HMO policy
Kaiser PPO ONLY,(NO HMO/POS)
Medicaid Wellcare, Amerigroup,Peachcare,Peachstate
Medica UHC network
PHCS (Private Health Care System PPO, POS
Principle/Southcare PPO, HMO, Promina NOT PAR: Principal Edge
Wellcare medicaid and medicare

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