TeleHealth at Family Care

This page is a step-by-step overview of Phone and TeleHealth appointments with your primary care provider at Family Care, PA. These visits are essentially secure audio and video conferences with your provider that can replace in-person office visits for many issues. The process for phone-only consultations is a bit easier (we just call you!), so this outlines the steps you’ll need to take in your Patient Portal account to establish a video connection.

You can use the Healow Application on your smart phone, or login to your patient portal using a computer (web cam and microphone required). The basic process is the same and we’ve included screen shots of both devices to help you navigate through either option.

The “waiting room” for your visit opens up 15 minutes before your appointment, so login early to make sure you are prepared.

Please call our office if you have any questions!

Joining a TeleHealth Visit on Your Smart Phone

This section covers how to register, check-in, and attend a scheduled video conference with your primary care provider by using a smart phone.

STEP 1: Download the Healow App.

Our electronic medical records system uses the Healow App to provide a secure messaging and information portal for our patients. You will need the app to participate in a TeleHealth visit.

STEP 2: Schedule an Appointment

Call us at 919-544-6461, send a request through your patient portal account, or complete this email request form to set up a time for your appointment. We offer two types of remote appointments:

  1. Phone Consultation. This is an audio-only phone call between you and your provider. This is used for consultations that do not require a physical or visual exam.
  2. TeleHealth. This is a video chat between you and your provider. This requires the patient to be on a device with a camera, speakers, and using an internet connection.

There is generally no cost difference between choosing either option, but some insurers have strict requirements for the diagnoses that are covered under TeleHealth.

STEP 3: Login to the App 30 minutes before your appointment.

After setting up your account and entering Practice Code “GIJCAA” to link your app to Family Care, you will be asked to provide your personal PIN to login. Once you login, you’ll visit your account’s main page.

If you do not remember your username or password, use the “Forgot Password” feature on the app or visit our portal’s main website to reset the information on a computer.

STEP 4: Click on the highlighted “Appointments” icon.

To Check-In for your visit, click on the top-middle “Appointments” button. This is the main screen for your Patient Portal account.

  • Inbox: This contains all updates and messages from Family Care. If you have new lab results posted, or your provider sends you a message, or you receive a bill, your Inbox will have the notice.
  • Medications: Lists your current medications and dosing instructions.
  • Check-In: Complete forms and vitals for upcoming visits. This is duplicated in the Appointments screen for upcoming visits within the next 30 minutes.
  • Find Appointment: This is completely useless. We wanted to allow more flexibility in scheduling than this app allowed, so we disabled this feature.
  • Trackers: Helpful apps to track blood pressures, weights, and measurements.
  • My Records: Summaries of previous encounters, diagnoses, medications, charges, etc.

STEP 5: Click “Check-In” for your next appointment.

This screen will list recent appointments (within the last 30 days) and all future appointments.

  • Map Icon: For in-person visits, the Map icon sends you to your preferred Map app with the destination set to our office at 1413 Carpenter Fletcher Rd, Durham, NC, 27713.
  • Check-In: Click this to advance to your upcoming video appointment.
  • Phone Icon: Click this to call our office by phone at 919-544-6461. Use this if you have trouble with any of these steps and need support.
  • Eye Icon: View details of this visit.
  • Appointment Alerts: Schedule push notifications to remind you of upcoming appointments.

STEP 6: View the “Appointment Details” Screen

Once you have found your upcoming appointment and selected the “Check-In” option, you will be directed to a screen with details and notes. This is one reason to sign in early!

  • Reminder: If you have upcoming appointments, you can always set additional reminder messages. Automatically, you will receive…
    • An email and portal notice 1-hour after making the appointment, so you can add the scheduled visit to any calendar or schedule you need.
    • A portal notice and a phone call 24-hours before the scheduled appointment time, to remind you of the visit.
    • A text message 22-hours before the scheduled appointment time, if you don’t answer the phone call.
  • My Notes: Pre-populate questions and concerns that you have for your provider. Tips…
    • Make bullet-point lists. Separate by condition or medications. Ask every question you have about a certain topic, then move to the next topic. Visits are primarily billed based on face-to-face time with your provider, so being prepared helps keep the cost of your visit down, as well.
    • What questions do you have? You scheduled an appointment for a reason. Write that reason down! Write any problems or concerns you have, and definitely all of the things you are doing well! Document your successes, along with your problems. Write what you want to tell your provider, and then tell them during your appointment.
  • Start Televisit. This becomes active within 15-minutes of your appointment’s start time. You will still need to enter vital signs, click this when you are ready to speak with your provider!

STEP 7: Enter your vital signs.

You have the option to leave fields blank, so please only complete items you have ACTUALLY measured. Do not guess! Just leave the field blank, if you are unsure. These values could impact your permanent medical record (spoken in the best elementary school principal voice you can imagine), so please make sure the values you enter have been verified.

If your visit is to diagnose an acute illness, please document your temperature and pulse rate. Enter these values as accurately as you can, with the average of multiple measurements. Please let your provider know of any struggles or inconsistencies you may have had with the documented results.

STEP 8: Wait in the Waiting Room!

You can enter the Waiting Room up to 30 minutes before your scheduled appointment. Click to Join, once the “Start TeleVisit” icon is enabled.

Because of our new, flexible schedule, we may be able to complete your visit early! The sooner you enter the TeleHealth waiting room (which opens 30 minutes before your visit), the sooner we can connect with you!

  • Review Vitals: If you want to view or edit any of the optional vital information you entered on the last screen, tap here to edit.

STEP 9: Connect!

Once your provider joins the virtual Exam Room, you’re all set! Make sure your microphone and speakers are enabled, of course. After your visit, our front desk staff will call you within 24 hours to schedule recommended follow-up visits, notify you of referrals, verify instructions, and collect any co-payments or deductibles owed.

Alternative to Step 3: Click on the Text Reminder to join the TeleHealth visit on your App.

15 minutes before your TeleHealth visit, you will receive a text message, if you have not already joined the appointment. This message will have a link to your patient portal’s account and (basically) start you at Step 4. If you have already enabled the app and logged in once, this link is very helpful to quickly join an upcoming appointment and skip some of the preliminary registration screens.

Joining a TeleHealth Visit on the Computer

This section covers how to register, check-in, and attend a scheduled video conference with your primary care provider by using a webcam-enabled computer.

STEP 1: Login to Patient Portal and Check Your Email

If you already have a Family Care Patient Portal account, joining from a computer is easy! You can login to your account and basically follow the same steps as the smart phone login,

One benefit to using a computer is being able to take a shortcut directly to your TeleHealth visit by clicking on our automated email that should arrive 30 minutes prior to your appointment. If you are already logged in to your portal account, clicking this takes you directly to the visit’s Waiting Room and you can skip most of the steps above!

STEP 2: Calibrate Your Settings

To be sure you have the proper audio and video equipment enabled on your computer, the Portal will send you to a verification screen the first time you set up a TeleHealth visit. If you get all Green Checks, you’re ready to go!

STEP 3: Join the Waiting Room

Once you reach this stage, your provider receives a notice saying you are ready for the visit. They should be able to join shortly after you arrive and may attempt to start the visit early, but most likely will join right around the actual start time of your visit.

If you have any questions, please call 919-544-6461! Thanks!

COVID Resources

Information Current as of 11:00am EST on July 6, 2020. 

North Carolina’s response to COVID-19 will continue to rapidly evolve. The most up to date information and guidance can be found at:

The respiratory disease named “coronavirus disease 2019” (abbreviated “COVID-19”), caused by a novel coronavirus named “SARS-CoV-2”, was declared a pandemic by the World Health Organization on March 11, 2020.

North Carolina now has community transmission of COVID-19. Therefore, we are moving to a different phase of our response efforts and will be further increasing our population-based community mitigation strategies. The goal of mitigation is to decrease spread of the virus among our population – especially for those who are at highest risk of clinical severity, and our health care workers – so fewer people need medical care at the same time. In addition, we need to implement strategies to conserve supplies and capacity so our health care workers can care for people who need medical attention even during the peak of the outbreak.

Appointments at Family Care

We have made a lot of changes to our scheduling and triage process over the last few months. Some changes you will notice include:

  • When you arrive for your appointment, please stay in your car and call 919-544-6461 to check-in.
    • We will screen you for possible COVID exposure over the phone and send a medical assistant to your car.
    • Our medical assistant will check your temperature, sanitize your hands, and provide you with a mask, if you do not have one.
  •  More than 50% of our schedule is now done remotely, through phone consultations and telehealth (video chats).
    • For med checks and visits that do not require a physical examination, we’ll try to arrange the visit remotely. This visit is structured similarly to a regular appointment, but saves you from unnecessary exposure to a medical office and helps with compliance to quarantine orders.
  • Our schedules have been expanded to limit the number of patients physically present in our office at any time.
    • More than 80% of our hours are now scheduled with only ONE patient in the office.
    • The remaining times will still have only one patient for a provider visit, but another patient may also be getting lab work. These are done in separate, contained areas in the building.
    • If you arrive early, you’ll need to wait in your car until your appointment time.
    • If you need to complete paperwork, please call our office and we will bring it out to you to complete in your car.

Government Orders

Know how COVID spreads

  • There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19).
  • The best way to prevent illness is to avoid being exposed to this virus.
  • The virus is thought to spread mainly from person-to-person.
    • Between people who are in close contact with one another (within about 6 feet).
    • Through respiratory droplets produced when an infected person coughs, sneezes or talks.
    • These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.
    • Some recent studies have suggested that COVID-19 may be spread by people who are not showing symptoms.

Wash your hands often

  • Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
  • It’s especially important to wash:
    • Before eating or preparing food
    • Before touching your face
    • After using the restroom
    • After leaving a public place
    • After blowing your nose, coughing, or sneezing
    • After handling your cloth face covering
    • After changing a diaper
    • After caring for someone sick
    • After touching animals or pets
  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.

Avoid close contact

Cover your mouth and nose with a cloth face cover when around others

  • You could spread COVID-19 to others even if you do not feel sick.
  • The cloth face cover is meant to protect other people in case you are infected.
  • Everyone should wear a cloth face cover in public settings and when around people who don’t live in your household, especially when other social distancing measures are difficult to maintain.
    • Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
  • Do NOT use a facemask meant for a healthcare worker. Currently, surgical masks and N95 respirators are critical supplies that should be reserved for healthcare workers and other first responders.
  • Continue to keep about 6 feet between yourself and others. The cloth face cover is not a substitute for social distancing.

Cover coughs and sneezes

  • Always cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow and do not spit.
  • Throw used tissues in the trash.
  • Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.

Clean and disinfect

Monitor your health daily

  • Be alert for symptoms. Watch for fever, cough, shortness of breath, or other symptoms of COVID-19.
  • Take your temperature if symptoms develop.
    • Don’t take your temperature within 30 minutes of exercising or after taking medications that could lower your temperature, like acetaminophen.
  • Follow CDC guidance if symptoms develop.

Family Care is in-network with Aetna!

Family Care is now in-network with Aetna Health Insurance!

We’re happy to add Aetna to the list of our current in-network providers (BCBS, Cigna, and UHC), especially since the majority of the City of Durham’s employees will transition to their new Aetna plans by the end of the year. This will also help our previously out-of-network Aetna patients reduce their primary care medical expenses at Family Care by more than 80%!

Aetna’s Medicare PPO is also the first Medicare plan to be considered in-network at Family Care, so seniors will have more options to reduce their healthcare costs!

If you have any questions or want to verify your coverage, please visit our Health Insurance page for more information.

You received a bill from a lab?

What to do if you received a bill from a lab for services rendered at Family Care, PA.

If you are reading this, you probably received a bill from a lab and had a question, so you were directed to this blog post for answers. There are a few pieces of information you’ll want to collect before determining if the bill is accurate.

Check the Explanation of Benefits (EOB) letter from your Insurer. For any claim against your health insurance, you will receive a statement of benefits from your insurer after the claims has been processed. This is an insurance-side verification document to be sure you are being billed the proper amount from the rendering facilities. This document also explains why something wasn’t covered – in many cases, the reason is something that can easily be fixed once you review the explanation and compare the result to your plan’s details.

Seriously, check your EOB. This step answers 90% of the questions by itself and helps answer the other 10% much faster. Please take the time to find and evaluate a paper or electronic copy of this document before asking questions or paying a bill.

  • Check statement dates. If your EOB shows the claim was processed after the bill was generated, you may receive an updated bill to reflect the changes.
  • Check denial codes. If something wasn’t covered, the EOB will tell you why. If you disagree with the reason and think it should have been covered differently, you still have a chance to fix or appeal the denial. If the denial reason makes sense, you’ll likely owe that amount.
  • Check each line item. Often, large bills are the result of a single, uncovered service, among a set of otherwise covered services. Narrow your focus on the specific line items that need to be fixed in your appeal.

If your insurer does not have record of the claim (eg. there is no EOB), then the lab did not file your claim with your correct insurance. You will need to contact the lab to update your insurance information and have them re-file the claim.

Find the portion of the EOB that states your patient responsibility. Based on the denial reasons stated in your EOB, we may have the potential to appeal and/or re-file your claim to have it re-processed by your insurer. If you think there is something that should have been paid, this annotated portion of your EOB will give you a clue as to why the service was denied. From there, we have a few options. In order of most likely, here are a few of the common situations we encounter:

Amount applied to deductible.

This probably means the reason/diagnosis used for the testing was not considered a preventive code. If your bill shows a primary diagnosis code starting with a Z, it was probably filed as preventive. If not, many plans have a lab deductible to meet prior to covering non-preventive services. If you believe the service should have been considered preventive, read this information regarding preventive wellness services and/or check your insurer’s benefit package to verify potential coverage.

Coinsurance owed.

Even after you meet your deductible, many plans still have a coinsurance percentage that will apply to lab services. Instead of paying 100% prior to meeting your deductible, you will pay a smaller portion (usually 10% or 20%) until you reach your out-of-pocket maximum. Basically, if your insurer allows $10 for a service, you can expect to pay $1. If you have not yet met your out-of-pocket maximum, you should expect to owe some amount for all non-preventive services.

Non-covered services.

This service is not considered a part of your insurer’s benefits package. This is rare, but it does happen. In certain cases, mostly regarding lab procedures, the lab and/or your provider may not be allowed to bill you for non-covered services. Always contact the rendering provider of any non-covered service within 2-3 weeks of receiving your EOB to verify your claim’s status to be sure. For services that are ultimately considered non-covered and billable, we can potentially have you pay our uninsured prices, rather than paying the lab directly.

Still have questions?

If you have gone through these steps and still have questions, we would be glad to help! Please include a copy of your EOB, a copy of the bill you received from the lab, and any information you have learned so far from your discussions with your insurer and the lab. This information will be needed to solve whatever complication you’re having with your claim. Good luck!

The New Patient Experience

Welcome to Family Care! To help you acclimate to our practice and adjust to a new way of doing things, we thought it would be helpful to outline exactly what to expect during your first visit to Family Care. Our goal with this page is to walk you through the process of becoming a new patient, including scheduling, billing, and contact processes, as well as the expectations we’ll have for you as our patient. We hope to cover every detail that you might consider relevant during your first few appointments to our office so you’ll know what to expect and feel more comfortable during your initial visits to Family Care.

How do I make an appointment?

Call 919-544-6461 or complete this form.

When will my appointment be scheduled?

Each of our providers schedules New Patient visits at certain times during the day. You will be able to select from any available upcoming new patient appointment times for the provider you prefer. Once you become an established patient, more possible appointment times become available.

  • Sabrina Mentock, MD: Not currently accepting New Patients.
  • Elaina Lee, MD: Accepts 2 New Patients per week.
    • Wednesdays at 9am and 11am.
  • Sarada Schossow, PA-C: Accepts 14 New Patients per week.
    • Monday & Tuesday at 2pm, 4pm, and 6pm.
    • Thursday & Friday at 9am, 11am, 2pm, and 4pm.
  • Frankee Rodriguez, NP: Accepts 14 New Patients per week.
    • Monday & Tuesday at 9am, 11am, 2pm, and 4pm.
    • Wednesday & Thursday at 2pm, 4pm, and 6pm.

The exact available times may vary by 30 minutes on any given day, but this is a good starting reference.

Generally, if you do not have a preference which provider or time slot you schedule, our next available new patient appointment is within 7-14 days.

Waiting List. We do have a waiting list that we keep for last minute cancellations, if you are somewhat flexible with coming in with less than 48 hours’ notice. To be placed on the waiting list, you must complete the New Patient Registration form and submit your completed New Patient Paperwork prior to your appointment. This helps us work you in for a visit quicker by having all your paperwork completed and ready to go before your visit.

To be added to the waiting list, please follow these steps:

  1. Complete our New Patient Registration form.
  2. Complete our New Patient Paperwork and email the completed documents to our office.
  3. Schedule an appointment for your New Patient visit.
  4. Ask the scheduler to add you to a cancellation list and provide alternative days or times that would be best for you. If we have any openings that match your availability, we will contact you to move your appointment to an earlier date.

What will I do at my New Patient appointment?

Your very first visit to our office will be structured differently than all future visits. Because you are new to our practice, we must get you setup in our system, establish your history, and create a baseline for your future medical care. This visit will cover these specific things:

  • Acute Illness & Injury. If the primary reason you are setting up a New Patient appointment is because you are sick or injured, we will address your symptoms and concerns related to an acute condition. If you are not currently sick, we’re glad you’re well! We would then skip this section and spend more time on your Future Care Plan, instead.
  • Medical History. Before your visit, we rarely know anything about your medical history. This is obviously very important, so we will review all your previous diagnoses, treatments, procedures, prescriptions, and medical problems. We need this information to help you become healthier. Once you have become an established patient, we will already have this historical information documented and you will not necessarily go through this same type of review again.
  • Current Medication Refills. If one of your reasons for establishing care with a new primary care provider is to continue medications that were previously prescribed by another provider, we can often prescribe these refills at your initial appointment. To take over prescribing a medication, we would first need records related to your prescription history. This includes office visit notes from your previous provider that indicate the diagnosis and condition for the medication, as well as the dates and amounts of your recent prescriptions. We cannot prescribe a medication for a chronic or long-term condition until we have this information, so you may want to ensure that your previous records are transferred prior to your appointment if this is important.
    • We do not prescribe controlled substances at your New Patient appointment. There are no exceptions. After reviewing your previous records, if your provider agrees that you should start or continue a controlled medication after your visit, you may receive a prescription at your follow up visit after signing our Controlled Substance Agreement.
  • Future Care Plan. After reviewing your medical history and discussing your concerns, your new primary care provider will establish a plan for your future medical needs. For most people, this involves scheduling your annual wellness exam and ordering recommended blood work to be drawn at your next appointment. If you started a new medication for a chronic illness or condition at your new patient appointment, you may be asked to follow up to check your progress after 30-180 days, depending on the medication. All new controlled prescriptions require a 30 day follow up visit.

Because of the amount of time it takes to establish you as a patient, we do not perform annual wellness exams or preventive services at your initial visit. Your New Patient visit is considered a standard, non-preventive office visit. Your preventive exam (aka. the “free” visit on most insurance plans) is usually scheduled as your second appointment to our office.

What changes after I have already established as a patient at Family Care?

Full Schedule Access. The reason we limit the scheduling for new patients is to ensure that our providers have the time and resources available to manage their existing patients. Each provider schedules 30-minute appointments and only has availability for a certain number of visits per week, so we want to be sure they have enough time to properly care for their existing patients. We analyze the average number of visits each patient might require per year and have calibrated each provider’s new patient volume to ensure that existing patient needs are met before we consider adding new patients.

Once you have established as a new patient, our full range of scheduling options will be open to you. Instead of selecting from 2-4 appointment times per day, you will have potential access to all 16-24 possible appointment times each day. We reserve 4 times per day, per provider, for existing patient “same day” appointments (we do not schedule these times until the same day of the appointment and only use them for acute illnesses), as well, which means you’ll usually be able to schedule a sick visit within 24-48 hours, if needed. These appointments are often taken before 10am, so call early!

Telephone / Portal Triage. We cannot provide medical advice for non-established patients, but we can help existing patients because we have an established medical history. As an established patient, you will be able to call or message our office for medical advice outside of an appointment. You will be able to call and talk about your symptoms with our nurse, and maybe seek a recommendation for an over-the-counter medication. In many cases, the advice you’ll receive may still be to schedule an appointment to fully evaluate your concerns, but you can at least talk with someone prior to the visit.

Annual Wellness Exams. You will be able to schedule your annual preventive exam. We do not perform annual wellness exams during your first visit to our office, so the New Patient visit is necessary if you’d like to schedule this appointment. This is generally advertised as the “free” preventive visit through most insurers, so we structure the appointment to comply with most insurer’s coverage standards to help you get the most out of this visit at no cost to you. For details on what this appointment covers, please read about our preventive wellness exams.

How much will my visit cost?

This is an important question! Unfortunately, there is no perfect answer, so we can only explain the possibilities. There are many factors that influence the cost of your visit, so hopefully this can set your expectations and help you understand how the costs are calculated. To help simplify the potential outcomes regarding your patient responsibility, we created this Flow Chart you can follow and have linked our Self-Pay Price Listing.

In general, appointments are billed based on the amount of face-to-face time you spend with your provider. New Patient appointments are generally 5%-10% more expensive than regular appointments for similar tiers of services, so your first visit is likely to be more expensive than subsequent visits.

A good estimate of the total cost of the visit is between $100 and $150. If you do not have insurance, or have not met your deductible, you can expect to pay this amount at checkout. If you have a co-payment, you can likely expect to just pay your co-payment amount.

If you have any additional tests (eg. EKG, flu/strep testing, etc.), you can expect additional fees for those services. These services may be covered under your co-payment, or they may be considered part of a separate “Lab-Only” deductible that many co-payment plans feature.

Basically, a short visit with no testing is relatively inexpensive, while a long visit with many tests would be relatively expensive. Most visits fall somewhere in-between, so we use ~$125 as a good starting point for your expectations, which you can adjust after considering everything you’d like to cover during your visit. If you have any specific price questions that are not available on our Uninsured Price List, please contact our office for a custom quote.

We hope this has been helpful! If you have any questions, please ask! 

Appeal Denial, a Play in 4 Acts

The transcript below is a real email conversation I had with a patient who was trying to appeal a denied service. Reading this might help you avoid some of the delays we had with the appeal denial process and give you some direction on the steps you need to take if you want to file a claim appeal. The example refers to CPT Code 93880, which is a CIMT test performed at our office and often denied by out-of-state health insurance companies. You can potentially adapt the conversation to any CPT code, service, and price, as the process is very similar for appealing almost any denied service.

If you have any questions, please contact Ryan!

The Appeal Denial Begins (Act 1)

ME: We just received a denial for your CIMT test from February stating it was a “non-covered service” on your plan. That is the only information we received on our end – would you possibly be able to share the information on your statement with me so I can figure out if there is anything we can do for the appeal denial? Depending on why they determined it to be “non-covered,” we may have a few options available to get it covered. Thanks!

PATIENT: How much is it if it isn’t covered? I could dig into it a bit more, but if it’s hundreds of dollars, I’ll be extra motivated. 🙂 Are they usually covered by patients’ coverage?

ME: Yeah, it is usually covered. I was surprised to get the denial. It was $198.65, so it’ll probably be worth trying. I kind of enjoy trying to win these appeals, so I hope you’ll give it a shot! 🙂

PATIENT: I’d love to give it a shot! I’ll put that $200 to much better use. Is there any information I can send along in the meantime? I have had poor cholesterol and my family has a history of heart disease. The test revealed some unfortunate news about my “arterial age” and led to a cardiologist visit. Does that help my case? 🙂

ME: Your EOB from your insurance will probably have more details – I have attached the version I received on my end. Can you see what details yours shows? I’m not sending you an invoice since I think we can get it covered, but I can if that might help. A letter of medical necessity is one of the last options we have for an appeal, so that information should help if we get to that point. Hope it is easier than that, but we’ll see what your EOB says and go from there. Thanks!

Eight Weeks Later (Act 2)

PATIENT: Still no EOB in the mail. I wonder if I’ll ever get anything. Could we move forward in some other way?

ME: Do you possibly have electronic-only EOBs enabled? Can you login to an account with your insurance and look at your claims?

PATIENT: Good thoughts. I do have access to my online account and there is an EOB in there! I attached it. There’s not much more in there, unfortunately. What can I do to help this effort?

ME: You may need to call them to get a better reason why it was considered non-covered. Sometimes, they just accidentally call it non-covered and as soon as you try to ask them why, it magically gets fixed immediately. The EOB is good to have if we’re filing an appeal, though, so that can be your proof of a denied claim (one of the three things they’ll probably need to initiate an appeal). I know it’s a hassle, but it’s really helpful to have an actual reason why it is non-covered before trying to submit anything just so we don’t run into the same problem after an appeal.

Someone at your insurer’s customer service department should be able to answer this question: “Why was CPT Code 93880 considered a non-covered service under my plan?” The process for an appeal denial is pretty much the same no matter what, but we’d give them different content depending on why they claim its non-covered. I hope that helps!

PATIENT: Great, thanks Ryan! I’ll give them a call soon and ask that exact question. I’ll be in touch.

Two Weeks Later (Act 3)

ME: Just an update to let you know BCBS requested all records related to the CIMT service. I just sent them about 20 pages worth of notes your provider thought were relevant, so we’ll see how they respond in about 4 weeks. You should get a long letter in the mail if it is denied again, or a short letter if they approve it. Your letter usually arrives about 2 weeks before ours, so let me know which you get and I can start fixing the new outcome a little sooner.

PATIENT: That’s great! Thank you for staying on top of this, Ryan. I have so much else to do during the day, I’ve been kicking the “call BCBS” can down the road. It sounds like they’re still in the process of determining whether it should be covered. I appreciate it, as always.

Three Months Later (Act 4)

ME: Have you heard anything yet? I received a appeal denial saying it was duplicate (meaning they didn’t change their mind about it being non-covered) a few weeks ago, but nothing else. Did you happen to get a full explanation of the appeal’s denial? Thanks!

PATIENT: Huh… you know, I never received anything more in the mail, and I never checked back up on my dashboard. I’m doing that now…Okay, done looking it up. It does look like I have 2 outstanding claims and I owe ~$200, but that seems lower than I recall it being. Both are for “Vascular Study.” Let me know if there’s any more info I can get you. I should probably pay this dang claim if I haven’t already.

ME: That kind of confirms what I got – just hoping for better news from you. I’ll send you an invoice so you can use your flex card to pay the balance. Thanks for the reply!

2019 NC State Health Plan – Enrollment Options with Blue Cross Blue Shield (BCBS)

Last year, I wrote a comparison between the two options available to state employees through the NC State Health Plan to help people understand the differences between the plans and hopefully make a better decision when selecting a plan for their family. I’m updating that article for to include the changes for the 2019 NC State Health Plan here.

For the 2019 benefit period, North Carolina state employees have two possible choices for their health insurance plan: 70/30 and 80/20.

This article will cover the differences between the two plans and identify the types of families that would benefit from each option. I think the NC State Health Plan is one of the best health insurances you can have in North Carolina, so you are already somewhat ahead of the game with either option. However, because the two plans offer very different benefits, there is usually a “better” choice for everyone and the difference could be significant.

The plan did not actually change much for 2019, so I’ve essentially re-used most of my article from last year and updated it to include the new numbers. I hope this helps!

80/20 vs 70/30 NC State Health Plan Comparison

While most people focus on the cost of their monthly premium, that is not the only factor in your yearly healthcare expense. Sometimes, it makes more sense to pay a higher premium for better coverage if you know that you’re going to need that coverage during the year. Instead, you should try to minimize your total healthcare expense, which includes your premiums, deductibles, copayments, coinsurances, and other out-of-pocket expenses that you’ll have to pay during the year.

This is a direct, side-by-side comparison of the main financial factors that come in to play with these two NC State Health Plan options. While most people focus on the cost of their monthly premium, that is not the only factor in your yearly healthcare expenses. Sometimes, it makes more sense to pay a higher premium for better coverage if you know that you’re going to need that coverage during the year.

Instead of focusing on your premium payment, you should try to minimize your total healthcare expense, which includes your premiums, deductibles, copayments, coinsurances, and other out-of-pocket expenses that you’ll have to pay during the year. There are plenty of exceptions that apply to most situations, but understanding these key terms and aspects of the NC State Health Plan should help you make a reasonable prediction for your costs and set you up to figure out your own unique circumstances.

Below, I have split each of the factors into four basic sections:

  • Description of the term
  • The actual specs from each of the two plans
  • What the difference between the two plans means in concrete terms
  • And a “math” section that outlines how you can calculate your expected annual expenses using those numbers

Enjoy!

Premium

Description: Your NC State Health Plan monthly premium is the simplest cost you’ll have to calculate. These are your fixed costs and the amounts you’ll be paying regardless of the real healthcare expenses you’ll have during the year. This number is 100% predictable, it does not change, and it is owed every month, no matter what.

  • 70/30: $25/month ($300/year), or $598/month ($7,176/year)
  • 80/20: $50/month ($600/year), or $720/month ($8,640/year)

Meaning: You can consider these numbers to be the “floor” of your annual health expenses. At the very least, if you have health insurance, you will have to pay your premium. If you never went to the doctor at all, you would have to pay at least $300/$7146 each year to be covered under the 70/30 plan.

Math: Multiply your premium by 12 months to get your annual expense.

Copayments

Description: This is a flat rate, one-time expense that you incur with every visit to a medical provider for almost any reason. If you visit a PCP or specialist, expect to pay at least this much for your appointment.

  • 70/30: $40 for Primary Care Provider; $100 for Urgent Care; $94 for a Specialist
  • 80/20: $10 for Selected PCP or $25 for Any PCP; $70 for Urgent Care; $80 for a Specialist (a $35 increase from $45 in 2018)

Meaning: Try to predict how many times you’ll need to visit the doctor in a year and consider how much you will save from the difference in the copayment amounts. If you have been seeing the same doctor for a few years, they may be able to help you predict your expected number of visits and let you know what your provider’s plan for the next year might include.

Math: The 80/20 NC State Health Plan will save you $30 per visit to a PCP, $30 per visit to an Urgent Care, and $14 per visit to a specialist. Multiply your expected number of visits to each type of provider to figure out how much money you’ll save on your copayments by choosing to upgrade to the 80/20 plan.

Coinsurance

Description: This is a variable rate that only applies after your deductible has been met. After you have met your deductible, you will owe this percentage of all health expenses incurred until you meet your annual out-of-pocket maximum.

A better way to think of the deductible/coinsurance relationship is to consider two periods: before you meet the deductible, and after you have met the deductible. Before, your coinsurance is effectively 100%, because you pay for everything. After, your coinsurance gets reduced to either 20% or 30%.

  • 70/30: 30%
  • 80/20: 20%

Meaning: If these plans were sold at a retail store, you might see this advertisement: “Buy $1,080 worth of healthcare and get your next $4,388 in purchases at 70% to 80% off!” After the plans reach their deductibles and coinsurance begins to apply, you’ll pay significantly less for every bill the rest of the year. Because you are paying more for the fixed cost of the higher premium, you’ll need to pass this point before the 80/20 plan eventually catches back up with the 70/30 plan for total expected expenses.

Math: Try to predict how many times you’ll need to visit the doctor in a year and consider how much you will save from the difference in the copayment amounts. If you have been seeing the same doctor for a few years, they may be able to help you predict your expected number of visits and let you know what your provider’s plan for the next year might include.

A decent estimate for visit costs would be $100 for a PCP visit, $200 for an Urgent Care visit, $300 for a Specialist visit, $500 for a MRI/CT, $2000 for an outpatient ER visit, and $5000 for an inpatient ER visit, per day. The 80/20 NC State Health Plan will save you 10% after your deductible, so you can add up the totals for however many of those services you’re expecting to use and discount 10% for the 80/20 plan to calculate your total savings.

Deductible

Description: This is the amount in health expenses you’ll have to pay for before your insurance starts paying for the services you receive. Consider this a yearly down payment on your future care, to be paid as you go when necessary.

  • 70/30: $1,080 Individual / $3,240 Family
  • 80/20: $1,250 Individual / $3,750 Family

Meaning: Under either plan, you are on the hook for at least the first $1,080 in health expenses each year, with another $170 added under the 80/20. There are differences in copayments and prescriptions that mean the 80/20 plan will save you money in other ways during the year, but this will become a factor if you receive any of the wide variety of services that fall under your deductible.

Math: Once you know which services will be applied to your deductible, the cost calculation simply 100% of the cost until you’ve met your deductible. After your deductible has been met, your coinsurance will begin to apply.

A chart that maps your actual health expenses as compared to the differences in out-of-pocket expenses for the 80/20 and 70/30 NC State Health Plan.

Maximum Out-of-Pocket

I think the difference between the way out-of-pocket maximums are calculated carries one of the most important distinctions between the two plans, so I’m giving it a special section.

On the 80/20 plan, there is an “out-of-pocket maximum” of $4,890 for an individual (was $6,850 in 2018) and $14,670 (was $14,300 in 2018) for a family. This is the total amount of money, not including your premiums, that you would possibly ever have to pay for your healthcare in a single year. Even if you were in the hospital from January to December, this is the most you’d have to pay on the 80/20 plan (see assumptions).

However, on the 70/30 plan, there is no “out-of-pocket maximum.” Instead, the 70/30 plan has a cap on the “coinsurance maximum” at a $4,388 / $13,164 rate. Since we just covered how both plans have a deductible and the coinsurance applies to expenses after the deductible, you would think these would just be interchangeable terms. In a kind of sneaky way, this is slipped in as the biggest single category of expense for people who do end up meeting their maximums. Why?

Calling something an “out-of-pocket maximum” means it includes all deductibles and copayments. Literally, everything that the patient must pay for is included in that amount. When it is termed a “coinsurance maximum,” that very specifically applies only to patient responsibilities that are deemed coinsurance; deductibles and copayments are not included in this total.

Basically, you can interpret this to mean that the 80/20 plan only has a $3,640 “after deductible” coinsurance maximum that includes pharmacy benefits, while the 70/30 plan has a $1,080 medical deductible, $3,360 pharmacy deductible, and $4,388 coinsurance maximum separately. While the final out-of-pocket expenses are similar, the methods they each use to get there accumulate at different rates. Depending on where you fall on your expected usage, one side could still make a substantial difference.

Prescription Coverage

There are too many possible variables to really give a simple, universal estimate for prescription expenses, but I can at least guide you on how to figure out your own costs. It is easy to calculate the minimum ($0, because you don’t use prescriptions) or the maximum ($2,500/$3,360 when you reach your pharmacy maximum) expense, but everything in between is pretty much situational. To calculate your expected prescription costs per year, follow these steps:

  1. Make a list of your medications. All of them, even over-the-counter meds and the ones you forget to take.
  2. Look up every medication on your formulary. This is the document where you can find your drug’s “tier,” a hierarchical cost-based categorization system that the NC State Health Plan uses to decide how much you’ll pay for each drug. If you cannot find the drug, you will need to contact your insurer directly to ask about a more specific medication than they have listed in the general formulary. Estimate retail value for over-the-counter medications.
  3. Multiply the number of refills you’ll need by the copayments / out-of-pocket expense for each tier. You pay more for higher tier medications, so taking lower tiered or generic medications could potentially save a lot of money each year.

This is a somewhat oversimplified method, but it should give you a good starting point. There are a few other ways to reduce your costs:

  • If you take a Tier 2 or Tier 3 drug, contact your provider to see if a Tier 1 drug might be a suitable alternative. This may require an appointment or additional lab work, so take that extra cost into consideration.
  • If you expect to be taking the medication for at least the next three months, you may be able to get a cheaper, 90-day supply by using a mail order pharmacy.
  • If you don’t use GoodRx.com, sign up. We have discount cards at our office and would be glad to share – they send 1,000 of them every 3 months and we have way too many. Please, take them. I’ll give you 10, just in case you lose nine of them. Regardless of your insurance coverage, this site helps you find the best prices at different pharmacies and can save you hundreds of dollars on most non-formulary medications.

Necessary Details of the NC State Health Plan

This information should give you a good starting point for predicting your coverage, but it is not comprehensive. These are other categories of health expenses that you need to be aware of and factor in to your own personal calculations.

  • Out-of-network expenses. Visits to an out-of-network provider are “covered” under a separate set of benefits from your in-network out-of-pocket expenses. These benefits are usually at least 50% worse and there are a lot more things that are denied or non-covered, so it is best to stay in-network for almost anything you do.
  • The number of people covered in the Family plan. The “Subscriber + Family” option covers one kid, two kids, ten kids, or as many kids as you want to have. No matter how many kids are included, the Family Maximums are the same. If you consider the smallest “Family” to be 3 people, the price per person gets reduced significantly with every additional child.
    • 3 people; $14,670 maximum = $4,890 / person, maximum
    • 4 people; $14,670 maximum = $3,667 / person, maximum
    • 5 people; $14,670 maximum = $2,934 / person, maximum
  • The amount of work you are willing to do. This especially applies to prescription coverage. Some of the most effective ways to save money will require you to call your insurer, fill out forms, document everything, track of receipts, and/or generally make you deal with your insurer’s customer service department. Assess how likely you are to make that effort, if needed.
  • Unexpected Expenses. You might get lucky, but remember that you are trying to predict 2019 health expenses for your entire family in October 2018. Things can change in the next hour, much less 2-14 months from now. If you choose the 70/30 plan, figure out how comfortable you are with having an accident and meeting the maximum, then consider that additional risk when selecting a plan.

Other NC State Health Plan Notes & Considerations

  • The “Free” Annual Wellness Visit is not included in the 70/30’s benefits, so your annual physical will have a $40 copayment just like any other visit. The 80/20 plan covers this at 100%.
  • For the 80/20 plan, Tier 3 drugs are applied to your normal deductible and coinsurance, instead of having a set copayment. While this probably makes the drug more expensive, having more expenses applied to a deductible is always a good thing for people who expect to hit their maximums. You could end up owing the pharmacy a lot of money early in the year, but then owe much less for all other health expenses combined for the rest of the year.
  • The 70/30 doesn’t cover ACA Preventive Medicines, either. Basically, you should just expect to pay more for birth control with the 70/30 plan, especially for branded medications.
  • Emergency room copayments are only a $37 difference, but the big part is in the 20% vs. 30% coinsurance owed. 10% of a single ER visit adds up quickly, so expect to pay at least $500-$1000 more for a single night’s ER stay with the 70/30 plan.
  • Your coinsurance kicks in sooner under the 70/30 plan ($170/$510 sooner for an individual/family plan), but your coinsurance rate is slightly worse. Because the 80/20 plan “catches up” with the 70/30 at a 10% rate, it would take $1,700/$5,100 in additional health expenses under each plan to reach a break-even point where you’ve paid the same amount in “deductible + coinsurance” under either plan.
  • The individual deductible on the 80/20 plan was reduced by $1,960, which is good news for everyone, but especially single employees with no dependents and families where one person generally uses most of the healthcare dollars on the plan.

Actions You Need To Take

It probably won’t be fun, but you still need to do this stuff.

  • Elect Your Plan. Kind of a weird way to say, “Choose a Plan,” but I guess we’ll go with calling it an election! You must choose the 80/20 or 70/30 plan. If you don’t make a choice, you will get defaulted to 70/30 and be charged an extra fee for the 70/30 plan for not making a choice.
  • Complete the Tobacco Attestation Credit. Even if you did it last year, you need to do it again. This saves you $60/month on your NC State Health Plan premium under every option.
  • Select a Primary Care Provider. There is a new link on the left side of your NC State Health Plan online account that allows you to change your PCP in just a few clicks. It was never too difficult to do over the phone, but any saved phone call to BCBS is a step in the right direction. We hope you choose Family Care!
  • Review Your Dependent Information. If applicable, make sure your spouse and kid(s) are enrolled on your plan. If you were married or had a kid since last enrollment, congratulations! Now make sure they are still on your plan! Double check that BCBS has demographic information like date of birth, mailing address, and phone numbers correct, as those can be a big hassle to correct later.
  • Print A Confirmation Statement. This is probably the most important thing you’ll do for yourself, so don’t skip this. I have heard so many nightmare stories and have listened to dozens of patients complain about being enrolled in the wrong plan on accident, and the only ones that I’ve seen win are the patients with their own receipts and records. Do not trust BCBS to get your information correct. Stay on top of it yourself and don’t let them make a mistake that costs you coverage, money, and sanity.

Summary

As with everything in healthcare, the standard “subject to individual determination” disclaimers always apply and nobody will, or should, give you a definite answer. I cannot tell you which plan you should choose, but I think you can use this guide to make that decision on your own.

All you can do is make the best estimate possible with the information you have at the time. Someone telling you they can accurately predict your actual health expenses is either lying, inexperienced, or delusional. Be ready to adjust if something does happen with your health and you need more extensive care than planned. Factor that potential into your decision and always be prepared for the worst-case scenario. I’ve found it is always better to be relieved things weren’t as bad as you thought, rather than being mad that they were worse.

For most people, your realized benefits under either plan will always be within a few hundred dollars of the other, so don’t stress out about the decision too much. This decision is not going to bankrupt you if you make the wrong choice. Either way, you will still have a plan that is better and cheaper than anything you could get on the individual marketplace.

Thank you for reading! I hope this helps you decide. Contact Ryan if you have any questions!

Good luck!

Assumptions

During the article, I left out mentioning many of the exceptions and individual circumstances that are possible with the NC State Health Plan. The article was already 3300 words, so I thought I’d save the trouble. Here are a few assumptions I made for all of the pricing and cost examples.

  • This is a breakdown of the distinct categories of expenses that you’ll have under either plan. Since it would be a little too confusing to talk about each of the 16 possible choices, I’m only using the “Subscriber Only” and “Subscriber + Family” plans as the low/high-end examples. You should adjust the numbers slightly if you choose the “Subscriber + Child(ren)” or “Subscriber + Spouse” options.
  • These numbers also assume that you will complete the Tobacco Attestation document and save $60/month on your premiums. If not, you should expect to pay an extra $720/year in premiums, but the rest of the expense calculations should remain the same.
  • I am also assuming you use a Blue Options Designated Specialist, visit your Selected Primary Care Provider for primary care services, and only visit in-network providers for all your healthcare needs. If you seek services under any other designations, you should expect to pay more.

Additional Resources

NC State Health Plan Benefit Booklets

Pharmacy Resources

2018 State Health Plan Enrollment Options

Last year, I wrote a comparison between the three 2017 North Carolina State Health Plan options available to state employees to help people understand the differences between the plans and hopefully make a better decision when selecting a plan for their family. The State Health Plan (NCSHP) makes up our largest group of patients and I know it helped at least one person, so I figured it might be helpful to do the same thing this year. The information in last year’s article is still worth checking out if you are new to health insurance, in general, but this year should be a bit simpler.

Because the state eliminated the popular CDHP option for 2018 enrollment, NC state employees are left with only two possible choices: 70/30 and 80/20.

The rest of this article will cover the differences between the two plans and identify the types of families that would benefit from each option. I think the NC State Health Plan is one of the best health insurances you can have in North Carolina, so you are already somewhat ahead of the game with either option. However, because the two plans offer different benefit structures, there is usually a “better” choice for everyone.

A video that discusses the changes and options available on the 2018 NC State Health Plan.

80/20 vs 70/30 State Health Plan Comparison

This is a direct, side-by-side comparison of the main financial factors that come in to play with these two health insurance plans. While most people focus on the cost of their monthly premium, that is not the only factor in your yearly healthcare expenses. Sometimes, it makes more sense to pay a higher premium for better coverage if you know that you’re going to need that coverage during the year.

Instead of focusing on your premium payment, you should try to minimize your total healthcare expense, which includes your premiums, deductibles, copayments, coinsurances, and other out-of-pocket expenses that you’ll have to pay during the year. There are plenty of exceptions that apply to most situations, but understanding these key terms and aspects of your plan should help you make a reasonable prediction for your costs and set you up to figure out your own unique circumstances.

Below, I have split each of the factors into four basic sections:

  • Description of the term
  • The actual specs from each of the two plans
  • What the difference between the two plans means in concrete terms
  • And a “math” section that outlines how you can calculate your expected annual expenses using those numbers

Enjoy!

Premium

Description: Your monthly premium is the simplest cost you’ll have to calculate. These are your fixed costs and the amounts you’ll be paying regardless of the real healthcare expenses you’ll have during the year. This number is 100% predictable, it does not change, and it is owed every month, no matter what.

  • 70/30: $25/month ($300/year), or $598/month ($7,176/year)
  • 80/20: $50/month ($600/year), or $720/month ($8,640/year)

Meaning: You can consider these numbers to be the “floor” of your annual health expenses. At the very least, if you have health insurance, you will have to pay your premium. If you never went to the doctor at all, you would have to pay at least $300/$7146 each year to be covered under the 70/30 plan. While the $720/month maximum premium seems steep, I would encourage you to try shopping for a plan on the individual marketplace and see exactly what kind of value you’re getting on the plan. The difference will probably be surprising. These premiums are very reasonable when compared with other options, especially considering the quality of the benefits of the plan.

Math: Multiply your premium by 12 months to get your annual expense.

Copayments

Description: This is a flat rate, one-time expense that you incur with every visit to a medical provider for almost any reason. If you visit a PCP or specialist, expect to pay at least this much for your appointment.

  • 70/30: $40 for primary doctor, $94 for a specialist
  • 80/20: $10 for primary doctor (Need to visit Selected PCP); $45 for a Blue Options Designated specialist

Meaning: Try to predict how many times you’ll need to visit the doctor in a year and consider how much you will save from the difference in the copayment amounts. If you have been seeing the same doctor for a few years, they may be able to help you predict your expected number of visits and let you know what your provider’s plan for the next year might include.

Math: The 80/20 plan will save you $30 per visit to a PCP, $30 per visit to an Urgent Care, and $49 per visit to a specialist. Multiply your expected number of visits to each type of provider to figure out how much money you’ll save on your copayments by choosing to upgrade to the 80/20 plan.

Coinsurance

Description: This is a variable rate that only applies after your deductible has been met. After you have met your deductible, you will owe this percentage of all health expenses incurred until you meet your annual out-of-pocket maximum.

A better way to think of the deductible/coinsurance relationship is to consider two periods: before you meet the deductible, and after you have met the deductible. Before, your coinsurance is effectively 100%, because you pay for everything. After, your coinsurance gets reduced to either 20% or 30%.

  • 70/30: 30%
  • 80/20: 20%

Meaning: If these plans were sold at a retail store, you might see this advertisement: “Buy $1,080 worth of healthcare and get your next $4,388 in purchases at 70% to 80% off!” After the plans reach their deductibles and coinsurance begins to apply, you’ll pay significantly less for every bill the rest of the year. Because you are paying more for the fixed cost of the higher premium, you’ll need to incur at least $1,700 in expenses AFTER you have reached your deductible before the 80/20 plan eventually catches back up with the 70/30 plan for total expected expenses.

Math: Try to predict how many times you’ll need to visit the doctor in a year and consider how much you will save from the difference in the copayment amounts. If you have been seeing the same doctor for a few years, they may be able to help you predict your expected number of visits and let you know what your provider’s plan for the next year might include.

A decent estimate for visit costs would be $100 for a PCP visit, $200 for an Urgent Care visit, $300 for a Specialist visit, $500 for a MRI/CT, $2000 for an outpatient ER visit, and $5000 for an inpatient ER visit, per day. The 80/20 plan will save you 10% after your deductible, so you can add up the totals for however many of those services you’re expecting to use and discount 10% for the 80/20 plan to calculate your total savings.

Deductible

Description: This is the amount in health expenses you’ll have to pay for before your insurance starts paying for the services you receive. Consider this a yearly down payment on your future care, to be paid as you go when necessary.

  • 70/30: $1,080 Individual / $3,240 Family
  • 80/20: $1,250 Individual / $3,750 Family

Meaning: Under either plan, you are on the hook for at least the first $1,080 in health expenses each year, with another $170 added under the 80/20. There are differences in copayments and prescriptions that mean the 80/20 plan will save you money in other ways during the year, but this will become a factor if you receive any of the wide variety of services that fall under your deductible.

Math: Once you know which services will be applied to your deductible, the cost calculation simply 100% of the cost until you’ve met your deductible. After your deductible has been met, your coinsurance will begin to apply.

A chart that maps your actual health expenses as compared to the differences in out-of-pocket expenses for the 80/20 and 70/30 plan.

Maximum Out-of-Pocket

I think the difference between the way out-of-pocket maximums are calculated carries one of the most important distinctions between the two plans, so I’m giving it a special section.

On the 80/20 State Health Plan plan, there is an “out-of-pocket maximum” of $6,850 for an individual and $14,300 for a family. This is the total amount of money, not including your premiums, that you would possibly ever have to pay for your healthcare in a single year. Even if you were in the hospital from January to December, this is the most you’d have to pay on the 80/20 plan (see assumptions).

However, on the 70/30 State Health Plan, there is no “out-of-pocket maximum.” Instead, the 70/30 plan has a cap on the “coinsurance maximum” at a $4,388 / $13,164 rate. Since we just covered how both plans have a deductible and the coinsurance applies to expenses after the deductible, you would think these would just be interchangeable terms. In a kind of sneaky way, this is slipped in as the biggest single category of expense for people who do end up meeting their maximums. Why?

Calling something an “out-of-pocket maximum” means it includes all deductibles and copayments. Literally, everything that the patient must pay for is included in that amount. When it is termed a “coinsurance maximum,” that very specifically applies only to patient responsibilities that are deemed coinsurance; deductibles and copayments are not included in this total.

Basically, you can interpret this to mean that the 80/20 plan only has a $5,600 “after deductible” coinsurance maximum that includes pharmacy benefits, while the 70/30 plan has a $1,080 medical deductible, $3,360 pharmacy deductible, and $4,388 coinsurance maximum separately. While the final out-of-pocket expenses are similar, the methods they each use to get there accumulate at different rates. Depending on where you fall on your expected usage, one side could still make a substantial difference.

Prescription Coverage

There are too many possible variables to really give a simple, universal estimate for prescription expenses, but I can at least guide you on how to figure out your own costs. It is easy to calculate the minimum ($0, because you don’t use prescriptions) or the maximum ($2,500/$3,360 when you reach your pharmacy maximum) expense, but everything in between is pretty much situational. To calculate your expected prescription costs per year, follow these steps:

  1. Make a list of your medications. All of them, even over-the-counter meds and the ones you forget to take.
  2. Look up every medication on your formulary. This is the document where you can find your drug’s “tier,” a hierarchical cost-based categorization system that your insurer uses to decide how much you’ll pay for each drug. If you cannot find the drug, you will need to contact your insurer directly to ask about a more specific medication than they have listed in the general formulary. Estimate retail value for over-the-counter medications.
  3. Multiply the number of refills you’ll need by the copayments / out-of-pocket expense for each tier. You pay more for higher tier medications, so taking lower tiered or generic medications could potentially save a lot of money each year.

This is a somewhat oversimplified method, but it should give you a good starting point. There are a few other ways to reduce your costs:

  • If you take a Tier 2 or Tier 3 drug, contact your provider to see if a Tier 1 drug might be a suitable alternative. This may require an appointment or additional lab work, so take that extra cost into consideration.
  • If you expect to be taking the medication for at least the next three months, you may be able to get a cheaper, 90-day supply by using a mail order pharmacy.
  • If you don’t use GoodRx.com, sign up. We have discount cards at our office and would be glad to share – they send 1,000 of them every 3 months and we have way too many. Please, take them. I’ll give you 10, just in case you lose nine of them. Regardless of your insurance coverage, this site helps you find the best prices at different pharmacies and can save you hundreds of dollars on most non-formulary medications.

The 2018 Decision Guide for the NC State Health Plan.

This information should give you a good starting point for predicting your coverage, but it is not comprehensive. These are other categories of health expenses that you need to be aware of and factor in to your own personal calculations when deciding on one of the State Health Plan options.

  • Out-of-network expenses. Visits to an out-of-network provider are “covered” under a separate set of State Health Plan benefits from your in-network out-of-pocket expenses. These benefits are usually at least 50% worse and there are a lot more things that are denied or non-covered, so it is best to stay in-network for almost anything you do.
  • The number of people covered in the Family plan. The “Subscriber + Family” option covers one kid, two kids, ten kids, or as many kids as you want to have. No matter how many kids are included, the Family Maximums are the same. If you consider the smallest “Family” to be 3 people, the price per person gets reduced significantly with every additional child.
    • 3 people; $14,300 maximum = $4,766 / person, maximum
    • 4 people; $14,300 maximum = $3,575 / person, maximum
    • 5 people; $14,300 maximum = $2,860 / person, maximum
    • etc.
  • The amount of work you are willing to do. This especially applies to prescription coverage. Some of the most effective ways to save money will require you to call your insurer, fill out forms, document everything, track of receipts, and/or generally make you deal with your insurer’s customer service department. Assess how likely you are to make that effort, if needed.
  • Unexpected Expenses. You might get lucky, but remember that you are trying to predict 2018 health expenses for your entire family in October 2017. Things can change in the next hour, much less 2-14 months from now. If you choose the 70/30 plan, figure out how comfortable you are with having an accident and meeting the maximum, then consider that additional risk when selecting a plan.

Other State Health Plan Notes & Considerations

  • The state removed the “Free” Annual Wellness Visit from the State Health Plan 70/30 benefits, so your annual physical will have a $40 copayment just like any other visit. Last year, this visit to cover recommended preventive screenings and testing was covered 100% for all plans.
  • For the 80/20 plan, Tier 3 drugs are applied to your normal deductible and coinsurance, instead of having a set copayment. While this probably makes the drug more expensive, having more expenses applied to a deductible is always a good thing for people who expect to hit their maximums. You could end up owing the pharmacy a lot of money early in the year, but then owe much less for all other health expenses combined for the rest of the year.
  • The 70/30 doesn’t cover ACA Preventive Medicines, either. I am unsure how that law is being implemented or supported right now, but basically you should just expect to pay more for birth control with the 70/30 plan, especially for branded medications.
  • Emergency room copayments are only a $37 difference, but the big part is in the 20% vs. 30% coinsurance owed. A 10% difference in the bill from a single ER visit adds up quickly, so you should really expect to pay at least $500-$1000 more for a single night’s ER stay with the 70/30 plan in you have not yet met your deductible.
  • Your coinsurance kicks in sooner under the 70/30 plan ($170/$510 sooner for an individual/family plan), but your coinsurance rate is slightly worse. Because the 80/20 State Health Plan “catches up” with the 70/30 at a 10% rate, it would take $1,700/$5,100 in additional health expenses under each plan to reach a break-even point where you’ve paid the same amount in “deductible + coinsurance” under either plan.
  • If most of your health expenses come from prescriptions, the 80/20 plan will save you $860 between the $2,500 and $3,360 level. However, the advantage changes if you have more than one person in your family with high cost prescriptions. Under the 70/30 plan, the individual and family have the same $3,360 deductible, while the 80/20 plan has a $4,000 family maximum. If more than one person expects to spend ~$2,000 or more on prescriptions, the 70/30 plan will save you an extra $640 on those medications.

Actions You Need To Take

It probably won’t be fun, but you still need to do this stuff.

  • Elect Your Plan. Kind of a weird way to say, “Choose a Plan,” but I guess we’ll go with calling it an election! You must choose the 80/20 or 70/30 plan. If you don’t make a choice, you will get defaulted to 70/30 and be charged an extra fee for the 70/30 plan for not making a choice.
  • Complete the Tobacco Attestation Credit. Even if you did it last year, you need to do it again. This saves you $60/month on your State Health Plan premium under every option.
  • Select a Primary Care Provider. There is a new link on the left side of your NC State Health Plan online account that allows you to change your PCP in just a few clicks. It was never too difficult to do over the phone, but any saved phone call to BCBS is a step in the right direction. We hope you choose Family Care!
  • Review Your Dependent Information. If applicable, make sure your spouse and kid(s) are enrolled on your plan. If you were married or had a kid since last enrollment, congratulations! Now make sure they are still on your plan! Double check that BCBS has demographic information like date of birth, mailing address, and phone numbers correct, as those can be a big hassle to correct later.
  • Print A Confirmation Statement. This is probably the most important thing you’ll do for yourself, so don’t skip this. I have heard so many nightmare stories and have listened to dozens of patients complain about being enrolled in the wrong plan on accident, and the only ones that I’ve seen win are the patients with their own receipts and records. Do not trust BCBS to get your information correct. Stay on top of it yourself and don’t let them make a mistake that costs you coverage, money, and sanity.

Summary

As with everything in healthcare, the standard “subject to individual determination” disclaimers always apply and nobody will, or should, give you a definite answer. My wife is a state employee and I am making this same decision for my family, so you can consider this my way of talking out the decision for myself. I cannot tell you which plan you should choose, but I think you can use this guide to make that decision on your own.

All you can do is make the best estimate possible with the information you have at the time. Someone telling you they can precisely predict your actual health expenses is either lying, inexperienced, or delusional. Be ready to adjust if something does happen with your health and you need more extensive care than planned. Factor that potential into your decision and always be prepared for the worst-case scenario. I’ve found it is always better to be relieved things weren’t as bad as you thought, rather than being mad that they were worse.

For most people, your realized benefits under either plan will always be within a few hundred dollars of the other, so don’t stress out about the decision too much. This decision is not going to bankrupt you if you make the wrong choice. Either way, you will still have a plan that is better and cheaper than anything you could get on the individual marketplace.

Thank you for reading! I hope this helps you decide. Contact Ryan if you have any questions!

Good luck!

Assumptions

During the article, I left out mentioning many of the exceptions and individual circumstances that are possible with the NC State Health Plan. The article was already 3300 words, so I thought I’d save the trouble. Here are a few assumptions I made for all of the pricing and cost examples.

  • This is a breakdown of the distinct categories of expenses that you’ll have under either plan. Since it would be a little too confusing to talk about each of the 16 possible choices, I’m only using the “Subscriber Only” and “Subscriber + Family” plans as the low/high-end examples. You should adjust the numbers slightly if you choose the “Subscriber + Child(ren)” or “Subscriber + Spouse” options.
  • These numbers also assume that you will complete the Tobacco Attestation document and save $60/month on your premiums. If not, you should expect to pay an extra $720/year in premiums, but the rest of the expense calculations should remain the same.
  • I am also assuming you use a Blue Options Designated Specialist, visit your Selected Primary Care Provider for primary care services, and only visit in-network providers for all your healthcare needs. If you seek services under any other designations, you should expect to pay more.

Additional Resources

Benefit Booklets

Pharmacy Resources

How do I know if I am being billed the correct amount for my visit?

How do I know if I am being billed the correct amount for my visit?

As most people can understand, figuring out exactly how much a particular medical service will cost can be extremely difficult. There are a lot of variables that factor in to the final cost of any care you receive, but it is still possible to get pretty solid information and set reasonable expectations for the most common types of services you will encounter. This post is designed to help you understand the basics of the billing process to help you identify any problems and know learn how to fix them.

When you are billed by any medical provider, they are usually working with the best possible information they can get about your insurance coverage at the time of service. However, regardless of how well they might be able to predict your coverage, providers are often still sometimes just as surprised as the patient when dealing with unexpected changes in coverage and quirks with different insurance plans. Because of this uncertainty, the amount you pay at the time of service may differ from the amount you actually owe.

No matter how much your provider may try to help navigate your insurance policy, the ultimate responsibility for the balance of a denied claim belongs to the patient. The total amount you will owe is called “patient responsibility” because you’re the one who will have to pay the bill and ultimately responsible for ensuring that you are paying the correct amount. Billing errors aren’t common, but they do happen and can be fixed pretty easily if you know how to find them.

PATIENT RESPONSIBILITY

There are three things that you’ll need to keep track of to know for sure if you are being billed the correct amount by your provider.

  1. The amount you paid at the time of service.
  2. The amount your explanation of benefits stated you would owe.
  3. The amount of the bill you receive from your provider.

Ideally, #1 and #2 are equal and #3 never happens because you’ve already paid the correct amount for the service you’ve received after the appointment. For standard visits and simple insurance plans with copayments instead of deductibles, this is usually pretty easy. Your insurance says you’ll owe $25 for a visit, so you’ll pay your $25 when you check out and know that the rest will be covered. Easy. Unfortunately, there are far more instances where deductibles, co-insurances, exclusions, and other insurance hurdles will also apply to your benefits and make things more difficult to predict.

These types of “high deductible / shared percentage” plans are becoming much more common and make up all of the possible options available on the health exchange for Durham County in 2017. Because the total bills you’ll receive for these kind of plans are very much dependent on factors that you can’t guarantee before the service is rendered, the amounts you are charged for certain services are much more unpredictable.

This is where a basic checklist comes in handy:

#1. Remember what you paid.

Because most FSA plans now allow you to submit an electronic PDF of your receipts for tax purposes, you probably don’t need to save a real paper receipt of your transaction. However, you will still need to keep track of how much you’ve paid, just like any other bill you might have. You can also always refer back to your credit card statement or look at your online banking history to reference the charges, if needed. Either way, if you actually get a bill, you’ll want to look up previous payments towards your expected out-of-pocket expenses for that service and make sure they are already deducted from your total balance.

#2. Check your Explanation of Benefits (EOB).

This is a statement issued by your insurance company and either mailed or uploaded to your online member services account about 2-3 weeks after every claim filed on your behalf by a medical provider or facility. Your final out-of-pocket expenses are usually listed under a column titled “total patient responsibility” and will your insurer’s reasoning for each balance owed will be detailed on this document after your insurance benefits have been assigned to your claim. If you receive a bill because your insurer says your plan didn’t pay for something, this document will tell you why.

#3. Check your bill.

If you know what you’ve paid (shown on your receipt) and how much you should owe (based on your EOB), you can pretty much figure out how much you’ll be billed after the service.

Amount owed on EOB – Amount paid at time of service = Amount still owed

There are always exceptions at each facility you visit that may lead to separate fees associated with their services, but those are usually relatively minor compared to the total cost of care. If you think there is a problem with the amount you are being billed, be sure to contact your provider and double check to see if there are any other fees or balances that may have contributed to the difference before attempting to contact your insurance.

FIXING A PROBLEM

So, you’ve looked at your EOB and examined at your bill and the two numbers still don’t match up. Or, worse, they do matchup and the amount is significantly higher than you were expecting. Now that you have identified a potential discrepancy with the bill, what do you do about it? Your first phone call depends on where you find the problem.

My EOB and the bill from my provider both show the same amount due.

This is a problem between you and your insurer. In this case, the problem would be that you disagree with the amount your insurer said you would owe since your provider’s information matches the insurer. This means that the problem lies at the start of the claim process where your insurance assigned your plan’s benefits to the claim they received. You thought you would owe one thing, but your insurance said something else.

Here are the steps you should take to work towards a solution:

  1. On your EOB, look up the “Remark Code” for the line items that are being denied. These are generally 2 or 3 digit alphanumeric codes that reference a longer explanation of denial later on in the document. This is a summary of the actual reason your insurance is using to deny this charge. If this summary explanation does not make sense to you based on how you understand your policy, you can call your insurance company for a full explanation.
  2. When you call customer service, be sure to have your insurance card and EOB in front of you so you can reference the date of service, amount billed, and the specific line item that you are questioning. They will be able to look up your insurance policy and re-examine the specific claim you are referencing at the same time to make sure your plan’s benefits were applied correctly.
  3. If your benefits were applied correctly, the representative can answer questions about your plan and help you understand how your benefits will be applied in the future so you can possibly avoid the same situation next time. Sometimes, payment is denied because they need to update information about your insurance plan, so you can answer their questions over the phone and take care of the balance in just a couple minutes. Learning more about your policy and how your insurance will process a similar claim could make a big difference in the long run.
  4. If your benefits were not applied correctly, the customer service representative should be able to notice the mistake and submit your claim for reprocessing. If this happens to be the case, you’ll want to get a reference number for the call and notify the provider that sent you a bill. The insurance will likely give you a quote like “we will reprocess this claim and send a corrected claim to your provider in 2-3 weeks.” Whenever they give you a timeframe, double it and then call your provider back to see if everything has been resolved.

My EOB says one amount owed, but the provider’s bill says something different.

If you have carefully looked at your receipt, EOB, and billing statement and still think there is a problem that is unrelated to how your insurance processed the claim, here are several logical explanations, in order of potential likelihood:

  1. You owed money for another claim. Most of the time, your billing statement only includes claim details for the claims with a balance owed. It is possible that your provider applied part of a payment you’d made to a claim that is not currently on your billing statement because that balance was covered.
    • You paid $100 at the time of service, but $40 went towards a balance from January and $60 went towards a balance from April. Because you also owed $100 from the April visit, you may receive a bill for $40 for that claim even though you paid $100 already.
  2. You owed money for additional fees and services not on the bill. Every practice is different, but there are always additional fees that you may have to pay for services that are not reimbursable by insurance companies. These include charges for things like missed appointments, form completion, records requests, and certain lab tests that aren’t covered by insurances. Part of a payment you made may have been applied to one of these types of charges.
  3. You had a previous credit applied. Sometimes, the system actually works in your favor and you might overpay for a charge up front. When this happens, you’ll receive a credit on your account that may be applied to future balances and reduce the amount you are charged at the time of service. If you were unaware of the credit, you may have expected a service to be cheaper than you thought when you paid.
    • You overpaid by $20 a couple months ago, so your provider only charged you $5 for your usual $25 copayment. When you look at your EOB, it shows that you would owe $25 for that visit, even if you only paid $5 that day.
  4. There was a mistake. Most financial correspondence between your insurer and provider is electronic and automated, but that doesn’t mean there aren’t mistakes. As the provider, we receive batches of claim data that includes dozens of claim rows and about 20 columns of payment information per claim from the insurer and we have to sift through every row, column, and number to ensure its accuracy. As you can imagine, it is very tough to get through this process and end up 100% perfect. Even at 99.9% accuracy, that means an average primary care facility will generate about 10 incorrect patient balances per month. Before getting upset or worried about the possibility of owing for a service, have your provider double check the claim first before attempting to appeal through your insurer.

You can easily identify which one of these situations is likely to apply to you by asking for a “transactional summary” of all your claims for a certain time period. All providers may call this report something different, so you’ll just need to ask for something that shows all the charges on all claims filed by the provider and how all of your payments were applied to your account over a certain time period. This will let you see, line by line, what caused the problem.

Most of the time, any changes to a bill with an amount that differs from your EOB will always be initiated by the provider who performed the service, so it’s best to start at the source if you want to fix a potential problem. I hope this has given you the knowledge to better understand your medical bills and the confidence to discuss them with your provider, if needed.

If you have any questions related to the content of this article or if you’ve experienced any other type of situation that I didn’t address, I’d love to read your comments below. Thanks for reading!

Happy Halloween!

Hallow-E’en, 1914
Winifred M. Letts – 1972

“Why do you wait at your door, woman,
Alone in the night?”
“I am waiting for one who will come, stranger,
To show him a light.
He will see me afar on the road
And be glad at the sight.”

“Have you no fear in your heart, woman,
To stand there alone?
There is comfort for you and kindly content
Beside the hearthstone.”
But she answered, “No rest can I have
Till I welcome my own.”

“Is it far he must travel to-night,
This man of your heart?”
“Strange lands that I know not and pitiless seas
Have kept us apart,
And he travels this night to his home
Without guide, without chart.”

“And has he companions to cheer him?”
“Aye, many,” she said.
“The candles are lighted, the hearthstones are swept,
The fires glow red.
We shall welcome them out of the night—
Our home-coming dead.”