Health Insurance 101

This month Illumine Magazine interviewed me for an article on how to choose a health insurance policy. The article explained the difference between a PPO, HMO and EPO and addressed a few other important issues. But there are a few other insurance FAQs that I wanted to answer for you. Below are some of the big things you’ll want to understand about your insurance policy.

This is very simplified! And still so very long! Please confirm all this information with your benefits provider. Or ask us at Chiropractic First for clarification. The rules of the insurance game are constantly changing. This is a general overview, but in no way a complete discussion of any of these topics.

In-Network versus Out-of-Network: Chiropractic First is In-Network with Blue Cross Blue Shield (BCBS). However, the way Blue Cross works, is that no matter what state your Blue Cross or Blue Shield plan is in, it can be accepted by all doctors across the BCBS network. In other words, if you have an Empire BCBS plan from New York or a Blue Shield of California plan, Chiropractic First (and all other BCBS doctors) are in your network!

If your doctor is not in-network with your insurance company, this does not mean you cannot use your insurance! It just means it will be more expensive. Some doctors who are out-of-network will still bill insurance directly. In this case, the insurance company will pay the doctor directly and then the doctor will collect the remaining amount due from you. Other doctors (like Chiropractic First) will collect payment from you up front. Upon request, we will give you what is called a Super Bill to give to your non-BCBS insurance provider. A super bill is a receipt with all the special codes an insurance company needs. You can send that super bill to your insurance company, and they will send you a check for a portion of what you paid, depending on what they cover. If you are interested in looking into that, here is more information about the questions to ask your insurance company.

Always make sure to ask your insurance company if a doctor is in your network. The doctor may “take your insurance” and bill the insurance company directly. But that does not mean they are in-network. Lots of very good doctors are going to be out of your network. That means seeing them may be more expensive. If you can afford it, it is always better to make decisions about what doctors to see based on who is right for you, rather than letting your insurance company decide for you. For example, studies have found that randomized groups of people who see a chiropractor instead of a medical doctor spend 66% less on health care!! Even if your chiropractor is not in your network, it’s going to be far cheaper to see them than pay 66% more for medical treatment from in-network doctors.

If the doctor is out-of-network, see if they have alternative payment arrangements. Chiropractic First is a member of a discount medical network called ChiroHealth. Joining ChiroHealth allows you to get discounted rates on your treatment at our office. Ask your other doctor’s offices what payment alternatives they have.

Deductible: In general, a deductible is the amount of money that you are required to pay before insurance starts paying. If you have a $500 deductible, you will have to pay $500 directly to your doctors before your insurance company starts paying anything. However, there are a lot of exceptions to this! Some things, like vaccines or screenings for colon cancer, are paid for in full by your insurance company even before you meet your deductible. The other major exception to this rule is discussed below in the Co-Pay section. It is confusing! But in general, your deductible is the amount you will have to pay for services before your insurance company starts paying.

You may have an in-network and an out-of-network deductible. If you see a doctor who is in your network, the money you pay them goes to your in-network deductible. If you see a doctor who is out of your network, it applies to your out-of-network deductible. Your out-of-network deductible is a higher amount than your in network deductible.

Out-of-Pocket Maximum: Out-of-Pocket is a really great feature of insurance. The Out-of-Pocket Max is the total amount you will have to pay each year for covered services. Once you spend that amount of money, covered services in your network will then be paid completely by your insurance company. Most people’s Out-of-Pocket Max is pretty high. We would all rather stay healthy than spend thousands of dollars a year in order to meet the Out-of-Pocket. But if you expect to have high medical bills, getting a plan with a lower Out-of-Pocket is a good idea.

Important to notice is that your Out-of-Pocket only applies to covered services. If your insurance company doesn’t cover something, you will have to pay for it even if you’ve reached your Out-of-Pocket. This most often comes into play at Chiropractic First when a BCBS plan only pays for a limited number of chiropractic visits. If your BCBS plan only covers 12 visits a year, the 13th visit isn’t covered. And BCBS is not going to pay for it, regardless of if you met your Out-of-Pocket or not. Insurance companies are sneaky!

Co-Pay and Co-Insurance: Ok, we are almost there.  This is the last thing that you really need to understand.

Have you seen that % sign on your policy or on your card? Maybe it says 80% or 70%?  That is your co-insurance. It means that your insurance company will pay 80% or 70% of your treatment. The remaining 20% or 30% is your responsibility. When you pay $6.80 or $13.60 for an adjustment at Chiropractic First, you are paying your co-insurance.

Co-insurance usually applies to treatments and procedures. The other thing you have is a co-pay. Co-pays generally apply to office visits—like new patient exams, reevaluations and other visits that are more focused on talking with a health care provider and less procedure driven. Co-pays are going to be round numbers like $30 or $50. Some polices only have co-pays and they apply to everything. Other policies only have co-insurance. But most have both.

If you have a medical treatment that costs thousands of dollars, it will be cheaper for you to have a policy that only has co-pays. Then that $5,000 treatment will only cost you $30 or $50. If you have co-insurance, that same procedure could cost you $500 or $1,000 because you pay a percentage. However, if you are doing a lot of smaller treatments, like chiropractic, you want a policy with co-insurance. The adjustments in our office usually are $68, if you have a co-insurance plan, you will pay somewhere between 10% and 30% of that. That will be much cheaper than paying a $30 or $50 co-pay!

Are there exceptions to this? Absolutely! Lots of them! But this is a start. Got questions? Leave them in the comments below. I will answer them for you either in the comments or in a future blog post.


2 Responses to “Health Insurance 101”

  1. Dana Pearl November 8, 2018 at 2:27 am #

    I didn’t know you accept BCBS. Does that include their HMO plans? If so, how does it work, since a primary care doc is supposed to make a referral?

  2. Lisa November 8, 2018 at 2:31 am #

    Thank you! What a helpful and easy to digest summary.

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