This is a helpful guide to understanding health insurance prior authorizations for radiology services and prescription drugs. This is the perspective of your primary care provider and should give you insight into the process to help set your own expectations. Your primary care provider is trying to help you navigate your insurance benefits and every plan is different, so this is a basic overview that covers the most common situations that we run into as a primary care provider.
What is a prior authorization?
Prior authorization is the process in which an insurance company asks for additional information from your healthcare provider in order to make sure that the medication that is being prescribed to you is the proper fit. While this is often required by insurance companies in an effort to reduce healthcare costs, they are additionally checking to make sure the medication is medically necessary, that up to date prescribing recommendations are being followed, and that any ongoing prescriptions are actually helping you. While this process may lead to a delay in filling your medication it does not mean that your insurance company will not allow you to take this medication. It does mean that you must meet certain requirements that deem this medication is right for you, and worth the expense, for your insurance company to allow this to be a part of your prescription benefits plan.
What happens when a prior authorization is required and how can you help?
The first group to know if a prior authorization is needed for your medication will be your pharmacy when they go to process your prescription with your insurance. Traditionally, the pharmacy is supposed to notify both you and your physicians office that prior authorization is required. However, as communication is key in this process, you can also contact your provider’s office to inform us. After notice of prior authorization being required, your physician’s office will begin the necessary steps to get approval. This does not mean that you do not have to do anything, as there are some ways in which you can help.
First, you can try to find out from your pharmacist or insurance company why your medication was denied. Examples of reasons include non-formulary medications, step therapy requirements, plan exclusions, or quantity limitations. If your pharmacy is not able to access this information, then you should obtain a copy of your formulary, which will detail all the medications that are or are not covered under your prescription benefits plan. By knowing why your medication is being denied your physician’s office can either alter your prescription to fit within requirements or will be able to compile the proper data to show why this medication is still the proper fit for you.
Second, make sure that your provider’s office has all the relevant information related to this drug. This may include information on any medications you may have taken in the past for this condition and why you cannot take them, any allergies you may have to certain classes of drugs, or any information that will show why you are not a proper candidate for trying alternative medications. While it may not be convenient digging up this information, the more relevant history that is supplied, the more likely that authorization will get approved. All information that is relevant to your medication authorization will be submitted to your insurance company along with the proper authorization forms.
How long do prior authorizations take?
Authorization forms vary based on the insurance company and the medication. while some can be completed relatively quickly, there are on occasion lengthy forms that require extensive documentation and collaboration with specialists. Additionally, you should be aware that providers are not in office every day and do have, on most days, full schedules. Once prior authorization forms are completed and submitted to an insurance company, the turn around time for a response is usually between 48 to 72 business hours. There are on occasion longer wait times, which we will try to communicate to you if applicable to your case.
What if my prior authorization gets denied?
If an insurance company chooses to deny your medication after a request for authorization, then your provider may choose to appeal the decision of the insurance company or may change the medication they have prescribed you. This decision will require communication with your provider and may entail you coming in for an appointment to try and discuss your options. If you do decide with your provider to appeal the authorization denial, please be aware that this is often a much longer process then the initial authorization and you may need to consult with your physician what to do in the meantime while waiting for approval. It is also important to note that if your insurance company does not approve your medication, it does not mean you cannot get it at all. You can still get this prescription as a self-pay patient and can often find coupons from your provider or online that will assist in the high cost of the medication. If you would like to do this please inform your physicians office so they may assist you in finding cost assistance options.
What if my prior authorization gets approved?
Congratulations! Once your authorization is approved by your insurance company you should be able to pick up your prescription immediately from the pharmacy. You should additionally receive notice from your insurance company of the approval via mail or web depending on how your insurance company communicates with you. It is important to note that your medication will be applied to your pharmacy benefits, so your cost for the medication will depend on your prescription coverage. In the off chance that your medication ends up still being too expensive, you can try to pay self-pay with coupons as detailed above or choose to make an appointment with your provider to discuss other options.
We hope this information was useful for you! If you have other questions please let us know!
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.
To help all of the State employees of North Carolina figure out which version of the State Health Plan would be best for them during the upcoming year, I thought we would attempt to review the differences between the three options – CDHP (85/15), Enhanced 80/20, and Traditional 70/30. The State has developed a very informative site with lots of details and specifics for the State Health Plan, so I won’t repeat anything you can find there. The goal of this post is to compare, line by line, what the numbers associated with each plan mean and which types of medical situations end up being the preferred option financially for each person once all expenses have been considered.
All State Employees should have received a “Decision Guide for Open Enrollment” packet from their insurer for the 2017 benefit period sometime in the past few weeks. You can use the “2017 State Health Plan Comparison” table on Page 8 in this booklet, or you can click on this link to get the PDF online. Here we go!
2017 North Carolina State Health Plan Comparison
HRA Starting Balance: You’ll notice that the CDHP plan is the only option with an Health Reimbursement Account (HRA). An HRA is basically a fund that your employer sets aside to pay for your qualifying medical expenses. With the CDHP plan, an individual has their first $600 in health expenses paid through their employer’s HRA. This is basically free money, as long as you need it and use it for things that are approved by your plan (eg. doctor’s visits, most prescriptions). Effectively, this splits the CDHP’s $1,500 deductible into two different periods, where you end up only having to pay once you hit $601 in expenses each year.
One thing to consider is that you actually need to use $600 in health expenses for this aspect of the plan to help. If you don’t use it, the $600 set aside for you in your employer’s account usually resets and lets the employer keep any unused funds to help reduce expenses the following year. While $600 is the same to anyone, this is an especially nice feature for people who expect their total health expenses to be less than $600 per year because they’ll never have to pay anything except their premiums.
Annual Deductible: A deductible is the amount of money you will have to pay out-of-pocket for non-preventive services before the actual benefits on your insurance plan will start to take effect. Of the three options available, the 70/30 has the lowest deductible, but that doesn’t mean it is the best plan. This means that the plan’s benefits kick in earlier, but the 70/30 plan also has greater expenses after the deductible and a much higher out-of-pocket maximum than the other plans. Other than just the dollar amount, there are two distinct differences in how these deductibles are applied:
The CDHP plan applies all medical expenses to the deductible. Your sick visits, specialist appointments, prescriptions – everything goes towards your initial $1,500 deductible. Other than the covered ACA Preventive Services, this plan doesn’t pay any of your health care expenses until after you have met the deductible.
The 80/20 and 70/30 plan have co-payments for PCP visits, urgent cares, and prescriptions so the deductible only applies to things like surgeries, labs, and hospital visits. While the deductibles are lower, they are also less likely to be met because they only apply to certain things.
Co-Insurance: You might notice that the co-insurance rate is also indicative of the name of the plan – eg. the 80/20 plan features a 20% co-insurance. The co-insurance is a percentage that requires the patient to pay a certain portion of approved medical services once their deductibles have been met. Basically, as a reward for paying 100% of everything out-of-pocket before you met the deductible, your insurance will now start helping pay your health expenses by reducing your portion to either 15%, 20%, or 30%, depending on the plan. Once you have met your deductible, this is the percentage of your health expenses you will be required to pay until you have met your co-insurance maximum.
Medical Co-Insurance Maximum: The 70/30 plan is the only one that has a medical co-insurance maximum. The other plans have their own maximums, so while this seems like a small bit of semantics, but it actually makes a pretty big difference in your possible expenses. The CDHP only has a combined out-of-pocket maximum that includes co-insurance and pharmacy benefits, while the 80/20 plan skips the co-insurance maximum and separates the out-of-pocket maximums between medical and pharmacy. By calling it a “co-insurance maximum” and not a “out-of-pocket maximum,” this number does not include the annual deductible that has already been paid.
This graphic does not include the separate prescription deductibles associated with the 80/20 and 70/30 plans.
Because the $4,350 out-of-pocket maximum in the 80/20 plan includes the $1,250 deductible, the 80/20 plan’s effective “co-insurance maximum” is really only $3,100. With the 70/30 plan, you’ll be paying the $1,080 deductible PLUS $4,388 more. A small difference, but one that costs over $1,200 if it actually comes into play. Also, it is important to remember that the 80/20 and 70/30 plans have separate deductibles for prescriptions, which we will get into soon.
Medical Out-of Pocket Maximum: As mentioned in the previous paragraph, the medical out-of-pocket maximum includes all out-of-pocket expenses a person would have to pay for medical services each year. This includes co-payments, co-insurances, and deductibles. For the 80/20 plan, this means you’ll have a cap on your medical expenses each year of $4,350. Because this number includes the deductible, you’ll basically be paying a $1,250 deductible, and then +20% of the next $15,500 in health expenses you incur (for a total of $4,350). This number puts a cap on your total annual medical expenses, so you can consider this the limit of a “worst case” scenario (not including prescription coverage).
Pharmacy Out-of Pocket Maximum: This is just like the medical out-of-pocket maximum described above, but only for prescriptions. The 80/20 plan and 70/30 plan both have separate deductibles for prescriptions, while the CDHP plan assigns both medical and pharmacy claims towards the same deductible. This makes it seem like the CDHP plan has better prescription coverage than the 80/20 or 70/30 plan, but those two only apply their deductibles to high tiered prescriptions that aren’t used by very many people. With the 80/20 and 70/30 plans, most of your prescriptions will be a set price for a 30- or 90-day supply, so most people will never really get close to meeting their limits with simple $5 and $30 co-payments per month.
Out-of-Pocket Maximum (Combined Medical and Pharmacy): The basic concept was covered in the previous two sections, but this number represents the “worst case scenario” for all of your out-of-pocket health expenses combined. There is no scenario where an individual will have to pay more than $3,500 on the CDHP plan, $6,850 on the 80/20 plan, or $8,828 on the 70/30 plan. This is a helpful number to know if you’re going to need a major surgery or hospitalization. These numbers are relatively low compared to today’s health insurance environment, where standard maximums are usually around $10,000 or $15,000 annually, so this is a one of the best aspects of the State Health Plan and a major selling point for most people.
ACA Preventive Services: These are the rates for certain services that have been categorized as “preventive” by stipulations in the Affordable Care Act, which has been adopted by the State Health Plan. You can check out the details of what is considered a preventive service on the State’s website – this includes things like your annual wellness exam, most vaccinations, and standard age-based guidelines and screenings. Preventive medicine has been proven to keep people healthier, so insurer’s are making a big push to ensure all of their members get these basic, cost-effective primary care services now so they can avoid having to pay for complicated, expensive hospital visits later. Because the services are preventive, and not urgent, the insurance penalizes you significantly for receiving these services out-of-network, so make sure the provider you see accepts your insurance if you want to receive these benefits.
Office Visits: So far, everything has basically seemed most favorable to the CDHP 85/15 plan. The next few topics are where the real benefits of the 80/20 and 70/30 plans come in, since they have co-payments for most medical services, instead of a deductible. While their deductible may be higher, it also applies to fewer things that you are likely to need. This is also the part of your benefits that applies to appointments at Family Care, if you were wondering.
For example, consider a single primary care visit for the flu – to make it easy, we’ll say its your first visit of the year.
With the CDHP plan, you are paying 100% of the cost of the visit because you haven’t met your deductible yet. This includes the doctor’s visit, flu testing, lab work, prescriptions, and any other services you may need. However, if the visit falls within the first $600 of your annual health expenses, the charges would be paid by your HRA account and you would not owe anything out-of-pocket. You would also get $25 added to your HRA, so you can think of that like a cash-back rebate towards your health expenses for using an in-network provider. After your HRA has been exhausted for the year, you will owe 100% of every office visit you have for the next $900, and 15% after that until you reach your maximum.
With the 80/20 plan, you would only pay a $25 co-payment for a doctor’s office visit, rather than having the charges applied to your deductible and owing 100%. Basically, you would save about $75 every time you went to a PCP and $215 every time you went to a specialist. If you had any testing or additional services (eg. flu test, breathing treatment, etc.), your deductible would apply in addition to your co-payment. This makes things relatively simple and helps people budget costs once they expect to have several office visits each year.
The 70/30 plan has the highest co-payments, but they are still not too far off from the 80/20 plan and the deductible applies to PCP visits the same way. You will have a higher co-payment, but still pay the same rates for additional services towards your deductible.
Urgent Care: Just like the section on Office Visits, but in an Urgent Care setting. There isn’t too much different about the basic process from office visits, so the main thing to notice is how much higher your expenses will be at an urgent care vs. your primary care provider. Whenever possible, you should always try to visit your primary care provider before attempting to go to an urgent care. For example, at this great independent primary care facility known as Family Care, we can guarantee either same-day or next-day appointments, so we can help you avoid the higher costs and lower quality of service that you’re bound to experience at an urgent care facility.
The nice thing is that the benefits for urgent care visits are identical at both in-network and out-of-network providers. Because the problem you are experiencing is obviously “urgent” if you are visiting an urgent care, your insurance company won’t care about the network and allow you to get treated wherever is most convenient. They charge a steep fee for this convenience, but it is still nice to know you won’t be charged more because of the network.
Emergency Room: Again, the CDHP plan applies charges to a deductible, while the 80/20 and 70/30 plan have co-payments associated with the visits. Depending on the significance of your reason for visiting the ER and how close you are to meeting your deductible, either one might be considered the best option for your situation. The one, and probably only, benefit to an ER visit is that you’ll likely go well beyond your entire out-of-pocket in just a few hours, so your healthcare will basically be “free” for the rest of the year. Yay for you!
Inpatient Hospital: This is reserved for actual hospital stays where the patient is admitted and kept in the hospital for some period of time. With all of the plans, you’ll only end up receiving the benefits in this row if you visit the ER and are then later admitted to the hospital. The insurance does not try to charge you twice after an admission, so the bump from an ER visit to an admission is not too drastic. The CDHP and 80/20 plans have an option to either get money back or have their co-payments waived if you visit a Blue Options Designated Hospital, so you should try to visit a preferred hospital whenever possible.
Prescription Coverage: The concept of tiers is pretty complicated, so I will go over this part in a separate post. However, the basics are still pretty much as the regular medical benefits the same across the three options. The CDHP has prescriptions applied to the same deductible as everything else, while the 80/20 and 70/30 plans have co-payments associated with different tiers of drugs. If you aren’t sure what these terms really mean, here is a good 2.5 minute video on what a drug formulary is and why your insurance has grouped different drugs into tiers.
For the State Health Plan, specifically, here are the links to the specific formulary for each plan. You should look up the medications you take to determine what tier they are classified under so you can get a good idea of your expected costs for that drug. The formulary changes all the time and the difference between a Tier 1 drug and a Tier 2 drug could be hundreds of dollars per year, so this helps keep you from being surprised when you show up at the pharmacy.
In my opinion, the State Health Plan is the best health insurance to have in North Carolina. Each plan has their specific benefits and drawbacks, but they are all significantly better insurance plans than the plans you’re likely to find available on Healthcare.gov. The problem is finding the plan that makes the most sense for how it will actually be used by you and your family. Every medical situation is unique, but here are some of the pros and cons of each plan to might help you make your final decision.
Pros: Potential for $0 premium and includes the lowest cost to add children and/or spouse. If you spend under $600 per person, your out-of-pocket expenses will be paid entirely by your HRA. This plan has the lowest out-of-pocket maximum, so this plan has the best “worst case scenario.”
Cons: You are required to pay for 100% of your expenses between $600 and $1,500 each year. You’ll have to pay for prescriptions under the same deductible as medical expenses. You’ll need to take additional steps to set up your HRA with your employer.
Pros: Lowest co-payments for PCP and Urgent Care visits, as well as most prescriptions. Pharmacy deductible is only $2,500, so meeting that deductible could help reduce overall costs if prescriptions make up a large percentage of your medical expenses.
Cons: Requires at least $15 per month, minimum, in premiums and has the highest premium cost to add family members. Potentially has the highest cost in a situation where multiple family members need extensive care and prescription coverage.
Pros: Has a lower premium than the 80/20, but still maintains a similar structure for PCP and urgent care visits. Has co-payments for Tier 3 medications, so certain medications might be cheaper than the other plans. One prescription deductible applies to the entire family.
Cons: Has the worst coverage after the deductible has been met of the three plans. Because the premium is similar to the CDHP, while the coverage is similar to the 80/20 plan, the segment of people that would have the best coverage for their unique situations is fairly narrow. Most people would be better off getting the CDHP or 80/20, but there is a definite middle group where this plan makes the most sense.
3 Things to Consider When Signing Up For Health Insurance
The problem that most people have with their health insurance plan is rarely with the actual coverage – people are generally only upset when their plan doesn’t cover something they thought it would or when they are surprised by some costly detail that wasn’t made clear at enrollment. Insurance companies don’t do the best job of educating patients on the actual details of the plans they are selling, but the information you need to know to set proper expectations is available if you know where to look. You’ll have to do some work and learn some pretty boring things, but you are the one who ultimately has to understand the details of your plan’s coverage, not your insurer. The point of this article is to help you understand the crucial differences between possible plans and help you feel comfortable with the coverage you choose.
The entire concept of health insurance is that you are basically making a bet on your health. The healthier you are, the less likely you are to use your insurance for high cost medical services. Your insurance company knows this and sets their prices accordingly. If the insurance company thinks you are going to cost $5,000 to cover this year, their goal is to set your total premiums and out-of-pocket expenses to more than $5,000 so they can make a profit.
This is the bet –who will get the better deal once all of your medical expenses have been paid?
The benefit structure of every plan offered by insurers is carefully calculated to give them the best chance of winning this bet. By understanding how your insurance plan works, you can put the odds back in your favor and make every dollar you have to spend on healthcare go much further.
There are three broad categories to consider when signing up for a new health insurance plan:
Cost – How much will I pay in out-of-pocket expenses?
Coverage – What services and medications will I have access to under my plan?
Network – Is my provider “in-network” with my insurance plan?
Each component is equally important and can have critical implications on the others. While it is almost impossible to get your expected costs 100% right before things actually happen, just having a very good estimate will help you budget accordingly and avoid surprises when you seek medical care. If you need help with this calculation, our Health Insurance Cost Estimator Tool should help give you a good estimate.
I hope the following pages will help you fully understand the benefits, and consequences, of your choices when you’re deciding between two possible plans.
Continue reading to go into further detail on each one of these components.
COST – How much will I pay in out-of-pocket expenses?
The most popular way to think about the cost of your health insurance plan is to focus on the monthly premium. This sounds good because you know the fixed costs associated with your plan and can seemingly predict exactly how much you will have to spend for coverage. However, this line of thinking leaves out the most important part by ignoring the variable costs a person might incur each year when they actually use their health insurance and visit their doctor.
To get a complete picture, you should compare a plan’s total expected out-of-pocket expenses, which factor in the possible copayments, coinsurances, and deductibles that you might have to pay for during the year in addition to your premiums. Signing up for insurance and paying your premiums to your insurer is not the only out-of-pocket expense you should expect if you need medical care. Much like car loan payments don’t cover the cost of the gas you need to put in the car, different health insurance plans might require significantly more “gas” than others if you actually want to take your plan out for a drive.
There are two primary things to consider when comparing the cost of two different plans – how much you’ll actually use your insurance, and how much you’ll have to pay in a “worst case scenario.” It is also important to remember that the out-of-pocket maximum does not include premium payments. Here is a quick plan comparison as an example.
Plan A:Higher Premium, Lower Out-of-PocketIf you have some chronic conditions that require frequent visits to specialists and take some high priced medicines, it will probably end up being cheaper to pay a higher premium for better coverage. Since you’ll be using the insurance often, it is comforting to know you’ll have a low limit on out-of-pocket costs when you actually need care. However, if you don’t end up using your insurance as much as you thought, you’ll be paying significantly more for unnecessary coverage.
Plan B:Lower Premium, Higher Out-of-PocketIf you are relatively healthy and rarely visit the doctor, a cheap premium with a high deductible makes sense because you want the lowest fixed costs possible. By not seeking medical care often, you can be pretty sure your variable costs will be low. You leave yourself more vulnerable to higher costs if something bad were to happen, like an unexpected emergency room visit or hospital admission, but that is a part of the bet you’re placing on your care.
Now to the fun part – Charts! Woo!
This chart compares the total cost of the healthcare you need with the total out-of-pocket expenses incurred if you were covered under either Plan A and Plan B. Because Plan A has a higher premium, the fixed cost of this plan has a higher floor than Plan B. If you don’t actually need to use the insurance, you will save money by choosing Plan B. The turning point occurs when the two lines intersect, which in this comparison is just over $4,000 in total health expenses. At that point, you’ll be saving money by choosing Plan A, even though the premiums will be more expensive.
Remember that “bet” we talked about earlier between you and your insurance company for who has to pay more of your healthcare expenses? The grey line represents the actual expense incurred to keep you healthy. As you can tell, the insurer is hoping they have enough members incur less than about $7,500 in health expenses each year to pay for the few members who will be extremely expensive to cover. The insurance wants to move that break-even point as far to the right of the chart as possible, while you’re hoping to intersect with their line as close to the left as possible.
Because it is impossible to predict the future and know exactly what services you’ll need, the best way to look at something like this is in terms of a “Best Case” / “Worst Case” scenario.
In a “Best Case” Scenario, where this person is perfectly healthy and never uses their insurance plan at all, Plan A will be twice as expensive as Plan B ($4,800 vs. $2,400) because the premiums are guaranteed payments regardless of how often you use your insurance plan. Plan A will actually still be more expensive than Plan B, overall, all the way up to the first $4,000 in out-of-pocket expenses. If you are unlikely to have at least $4,000 or more in annual health expenses, it makes sense to pay a lower premium and pay more of your own out-of-pocket expenses. Plan B would be a better choice as long as your expenses were lower than $4,000 during the year.
In a “Worst Case” Scenario, where this person ends up in the hospital for at least a few days and racks up $50,000+ in medical expenses, Plan B will be up to $2,600 more expensive because there is a higher deductible and out-of-pocket maximum limitation. The ACA put a cap on the out-of-pocket maximum that a patient would have to pay in such a situation, so the out-of-pocket maximum helps provide a safety net to ensure people don’t go bankrupt due to a medical emergency. In this case, Plan A would have better coverage.
These are overly simplified examples, but it shows how the total cost of healthcare for an individual can vary greatly just based on the type of plan they choose. Most likely, you will fall somewhere in the middle of the “Best Case” / “Worst Case” spectrum. The goal is to guess how close you are to one side or the other and how likely it is that you’ll need a high cost service during the year. You obviously can’t plan on having a serious accident, but the closer you get to that tipping point between the two plans, the more you might want to consider increasing your coverage to feel a little more comfortable with your financial risk in such a situation.
COVERAGE – What services and medications will I have access to under my plan?
There are several different ways to define “Coverage” when you’re referring to the details of an insurance plan, but this section will focus on the specific procedures, treatments, and prescriptions that your health insurance plan will approve. Basically, if you have a problem and you sign up for an insurance plan, you want to make sure that specific problem is something that falls under the benefits outlined in your plan.
The majority of what is required to be covered by insurances is either mandated by the Affordable Cart Act or derived from basic Medicare standards, so most of coverage details for medical services are the same across the major commercial insurers. But, that doesn’t mean they are all the same, either. Standard medical services like doctor’s visits, generic medications, and vaccines, will be accepted on almost any plan. However, if you are planning to do non-standard things, like cosmetic surgeries, treatment for rare or complex diagnoses, or special blood testing, you should really try to dig a little deeper into the plan to see what types of services are actually covered.
Essentially, the best way to think about how to get the “best” coverage you need is to start by seeking coverage for your most expensive service. Call your providers and ask for a price quote for certain types of visits you expect to incur during the benefit year. You will probably never get a definite answer (for a variety of really good reasons that we’ll answer in another post), but you should be able to get a ballpark idea what kind of prices you can expect. Ask for the specific CPT Codes that will be used for your procedures so you can tell your insurer exactly what you want to verify. Then, figure out which insurance plan covers the services that would cost the most if you didn’t have coverage because they will make the biggest difference in your bottom line for out-of-pocket expenses.
Here is a simplified chart that helps you visualize the types of priorities you should be making when selecting coverage. These are just working estimates and are by no means exact, especially considering that we just spent 1,000 words earlier in this article talking about how the “Cost If Covered” part of the equation could vary drastically depending on your plan. The point is to get a sense of the risk involved in having, or not having, coverage for a particular service.
Obviously, having coverage for the ER visits would be Priority #1 in this scenario. A single accident with no coverage could be financially devastating. But, those are generally few and far between for most people. Again, this goes back to the concept of placing a bet on your health expenses. You should go down the list of your expected health costs and find a plan that will pay for all of your highest priced items first, since they will have the biggest net difference on your potential bottom line.
After all, what would be worse? Having to pay an extra $75 because a PCP visit was denied, or having to pay an extra $45,000 because your hospital visit was denied? A PCP visit is more likely to occur, but the one time the hospital visit gets denied will potentially be the most devastating. However, because denials are still not too common if you have insurance, the most common factor that comes up when differentiating plans based on their overall coverage relates to prescriptions, as they can vary greatly depending on the plan.
Prescription Coverage Details
One plan could offer a certain drug at a $10 copay, while another plan might not cover it at all and either cost you $200 out-of-pocket or force you to switch to a different medication that your insurance prefers. Neither option is ideal, as you’re ultimately either poorer or sicker if your medication isn’t covered by your insurance. The insurers structure their drug coverage decisions based on the population of their insured, so finding the plan that best suits your patient profile could make a big difference in prescription costs.
So, how do you find out which drugs are covered on which plan?
To be confident in your choice, you should learn the details of the prospective plan’s drug formulary. Most of the time, a simple Google search with “Name of Insurance Plan, Drug Formulary List” in the search box will direct you to a PDF of the plan’s details. If not, there should a link on the insurance provider’s website or a phone number you can call to request a copy by mail or email. Prescriptions are one of the few health expenses you can make an accurate budget for up front, so it is important to know how your plan will cover the medications you are currently taking.
If you think your medication may be too expensive, even with commercial insurance, there may be programs that you can sign up for to reduce the cost. Please contact our office to discuss potential coupons, savings programs, and rebates that may be available for your medication. There are a lot of programs available to receive discounted prices on your medications, so it is ultimately in your best interest to take advantage of them when you can. If you are a current patient, ask for details!
NETWORK – Is my provider “in-network” with my insurance plan?
If you already have certain medical providers you prefer and want to make sure you’ll still have access to those providers, you’ll want to sign up for a plan that is accepted as an in-network insurance by your provider. If you stay in their provider network, the benefits on your plan will actually apply to your visits and you’ll receive a much lower rate than you would if you went out-of-network.
Because a person may see multiple providers and every provider has their own list of accepted insurances, you may run into a problem finding a single plan that is accepted by all of your preferred providers. Or, once you find that plan, you realize it is just way too expensive and cannot afford to sign up, so it is effectively inaccessible. In this situation, you’re going to need to make some type of compromise. You should start by assessing the true cost of the care you expect to receive and focusing on your largest possible expenses first.
No matter where the line of “affordability” lies, it is obvious that a PCP visit is at least “more affordable” than an emergency room visit. If you had to pay for one of those yourself, you’d much rather it be the $100 PCP visit rather than the $5,000 ER visit. While you can still manage to incur some pretty significant medical costs with frequent primary care offices and specialists, the out-of-pocket expenses will never be on the same level as a single visit to the hospital. Because primary care visits at Family Care average around $100 per visit if they are not covered, you’d have to have non-covered primary care visits twice a week for an entire year to match the cost of a single accident that landed you in the hospital.
With most health expenses, the bills escalate quickly due to a few common types of services:
Hospital Visits. Just one night in the hospital could cost more than $10,000 if you don’t have insurance, so these visits create the majority of medical debt.
Surgeries. A single surgery can sometimes cost more than $5,000 and often requires several costly follow up visits to make sure you are recovering well.
Tiered Medications. For drugs that have very specific indications or are considered upper-tier level medications, out-of-pocket costs can be up to $1,000 per month.
Because we are dealing with a situation where the insurance company is putting the obligation to pay the claim on the patient, this is basically an extension of our previous discussion on covered services, in general. Being “out-of-network” is one of the most commonly used reasons for an insurer to deny coverage for a particular service, so your plan’s network really has a big influence on your expected out-of-pocket expenses for a certain service. For example, the price of the same EKG at an out-of-network cardiologist could be 500% more expensive than if it were performed by an in-network cardiologist. That is actually kind of crazy when you think about it, but that is for another article.
There are a few different ways to find out which providers are in your network.
Call your insurance company. There is always a customer service number you can call to speak with a representative from your insurance. Ask them to send you a list of the providers in your area that accept your insurance. Usually, they will either read you a list over the phone, email you PDF file, or direct you to the content on their website.
Visit your insurer’s website. Most insurance plans have a “Provider Finder” tool somewhere on their website. Make sure you select the proper choices from all of the possible search filters to ensure that the list actually applies to your plan.
Call the provider. Each provider will know which plans they accept, so you could ask them as a starting point. Make sure know the name of the company (eg. BCBS, Cigna) and the name of the specific plan (eg. Blue Advantage, Choice Plus), as both of those are required to verify your coverage. Even if the provider says they accept your plan, you may want to double check with the insurer, anyway, as they will be the ones to ultimately process your claim and make that decision.
In order to maximize the amount of coverage you receive from your plan, you should try to stay “in-network” for as many services as possible. Plan to be “in-network” for the big expenses first, because that will make the most difference in your yearly out-of-pocket spending. There are many plans that actually offer pretty good out-of-network benefits, but they will still always be at least some margin less than your in-network benefits.
TLDR – A summary of the most important pieces of this article.
To summarize the last 3000 words, here are the main points I hope you learned from this article:
Your monthly premium is not the only factor you should consider when signing up for an insurance plan. You should consider your total out-of-pocket expenses, which include any copayments, coinsurances, and deductibles associated with the plan you choose.
The amount of money you have to pay each year can vary dramatically from one plan to another. You should try to estimate your expected health expenses for the year and find a plan that works for you.
You should seek coverage for your highest priced services first, and then worry about the lower priced items later. It is much easier to pay a $100 PCP visit out-of-pocket than it is to pay a $5,000 hospital bill.
If you are on medication for a chronic condition, you should ask to see a prescription drug formulary for your prospective plan to ensure that the medication you need will be covered by the plan you choose.
You should try to visit in-network providers whenever possible. Going out-of-network can significantly reduce the amount of benefits you will receive from your insurance plan.
If you are a current patient at Family Care and have any questions, you should ask Ryan for help! Contact us here.
VIDEOS – You prefer to watch videos about health insurance instead of reading articles? OK!
Because I completely understand that most people consider insurance to be completely boring and tedious, I tried to select some fun insurance education videos that I thought were actually pretty entertaining. These videos cover similar concepts to what we just discussed in this post and help emphasize the most important point of this whole article – that health insurance can be a good thing that actually make sense and occasionally helps you out, if you know what you’re doing. I hope you learn something that helps you even the playing field and get the most out of your coverage.
HUMANA – “How Do Deductibles and Copays Work?”
This is a really cool whiteboard “explainer” video on the different possible ways you could incur out-of-pocket expenses. I think this video does a good job on the concept of out-of-pocket maximums and deductibles, while making you really care for Gina as a person. At 1:59 in the video, I blame whoever was supposed to be spotting Gina on the ladder for that accident. It is also pretty cruel to just leave Gina on the ground while telling her she owes 20% of her medical bill for the fall. C’mon, video guy.
KAISER FAMILY FOUNDATION – “Health Insurance Explained – The YouToons Have It Covered”
This video covers the interesting journey of a beanie-wearing skateboarder that signs up for health insurance and gets into an accident because of a thieving raccoon. The video does a really good job explaining the risk factors involved with not having insurance and understanding the value of staying in-network for services. In the end, you’re actually a little bit upset the hero of the story didn’t learn from his experience when he chases after the raccoon again. You’re gonna get hurt again, dude! Let the raccoon go!
“MILIMAN, INC – Understanding healthcare costs: The employer-sponsored insurance system”
For the roughly 2/3 of people who don’t really care about the individual healthcare marketplace because they have health insurance through their employer, this video is for you. This helps explain the reason your premiums rise, or why your employer changes your plan every year to put more of the cost burden on the employee’s out-of-pocket expenses. Most of the time, if your individual contribution is increasing, your employer’s contribution is also increasing. It might not always be at the same rate, but just something to think about so you don’t always have to blame your company for being evil. The video also has a little bit of a “Tron” feel to it, so that is also kind of cool.
“GOATS ON A STEEL RIBBON” – Goats On a Steel Ribbon.”
You’ve probably had enough about insurance for one day, so you deserve a treat. These are goats on a steel ribbon. It is hilarious and mesmerizing and I really wanted the big goat to jump on the ribbon. I like to imagine that big goat jumped up on the ribbon just after the camera stopped recording and he is still there today, happier than all the goats in the land. You can do it, big goat!
Family Care, PA is a primary care medical facility located in the Durham, North Carolina. We understand that there are a lot of options for primary care in the area, so we know we need to provide a great service if we want to earn your trust. The large local hospitals are still very good, but we think that we provide a special type of care and attention to every patient that is not possible inside such a large system. Here are a few of the reasons we think you would really enjoy having Family Care as your primary care provider.
We get to know you personally. Our medical staff and providers take the time to get to know you during your visit, rather than rushing you through your appointment. You will never feel rushed during your visit and will have the opportunity to fully explain your symptoms and concerns. Our administrative staff also takes the time to get to know our patients and works with them to overcome common healthcare hurdles like coordinating specialist referrals, obtaining prior authorizations, requesting medical records, and appealing claim denials.
We are great patient advocates. At Family Care, being the best advocates possible for our patients is always our priority. When coordinating care, we always try to work within the structure of your insurance coverage to make sure the process is smooth and you are able to receive the full extent of your plan’s benefits. Our office policies regarding scheduling appointments, payments, and paperwork are all designed to provide the most efficient and affordable care possible.
We utilize available technology. Our office is able to provide efficient care by taking advantage of the wealth of technology available in healthcare today. We use an Electronic Medical Records system to manage our practice, which features an online patient portal. The portal provides 24-hour per day access to their own medical records at our office, including appointment reminders, prescription directions, and historical lab results.
We schedule 30 minute appointments. Unlike most primary care offices, we schedule each of our visits in 30 minute blocks of time. This does not always mean your visit will actually take a full 30 minutes, but the extra allowance does help make sure you are seen on time for your appointments and still have plenty of room to explain the full nature of your visit and concerns to your provider.
We are up front about our policies. We try to make the processes for how we provide efficient medical care as open and transparent as possible so our patients can understand the reasons behind them and why they are necessary, and beneficial, for our patients. We do our best to help patients understand their insurance policies and are always open about expectations, likely possibilities, and potential problems with obtaining coverage in certain situations.
We are able to be contacted easily. If there is anything else you need to know, just call our office at 919-544-6461. Family Care does not use a “phone tree” or automated operating system, so a real employee at our real office will pick up the phone when you have a question. If we aren’t able to answer the call, it is simply because we are at lunch (12pm – 1pm), or are helping another one of our patients in the office. If you leave a message, we will call you back shortly. Or, you can also contact us by…
Signing up for our patient portal and submitting a message directly to your provider through our EMR system.
Flying a drone to GPS coordinates “Latitude: 35.915967, Longitude: -78.894075″ with your hand-written message. Please print.
Note: Mention this option at your next visit and Ryan will give you a piece of candy.
We are grateful for the opportunity to take part in your medical care. We understand that you have plenty of options available to you – Durham is the “City of Medicine,” after all. We try to help in every way possible and hope you truly enjoy visiting our office. Thank you for giving us a chance to provide you with great medical care!
This page is a handy resource for patients at Family Care who have started taking Prolia. Please use the links below to access patient education materials that are required to be given to our patients before beginning treatment on Prolia. If you have any questions, please call our office and ask to speak with our nurse. Thank you!
Almost everyone at some point in their lives will suffer from acne outbreaks. While it can be embarrassing or frustrating, there are many easy ways acne prevention can help reduce the occurrence of breakouts. We tend to think that only teenagers should be plagued with pimples, but unfortunately, acne can be present our whole lives.
Make sure to wash your face with hands and not a washcloth as these may be abrasive to sensitive skin. Some acne washes contain Benzoyl Peroxide or Salicyclic acid, both of which can be very harsh to the skin. They may lead to peeling and redness, along with increased sensitivity to the sun.
If you try an OTC acne cream, be sure to test it on one spot first before applying to you whole face to minimize adverse reactions.
Neutrogena products. There are many Neutrogena products, but the ones I think are the best include the Oil Free Acne Wash for the face and Clear Body Wash, for back and chest acne. These products tend to be less drying to the skin than some of the other available washes.
Neutrogena moisturizer. There are several moisturizers with sunscreen in them that go on smooth and do not leave an oily residue. There are also overnight moisturizers to help fight off any dry skin.
Finally, if the OTC and home remedies are not working, you should come see us to discuss topical therapies or other medications to help reduce acne flares!
Sarada Schossow, PA-C is a primary care provider at Family Care, PA in Durham, NC. She has special interests in women’s health, adolescent and young adult health, and dermatology, including acne prevention. For more articles from Sarada, click here.
A grandfathered health insurance plan means that the plan does not have to follow the national healthcare reform guidelines implemented by our federal government as part of the Patient Protection and Affordable Care Act (ACA) in March 2010.
Job-based grandfathered plans. Job-based grandfathered plans can still maintain their grandfathered status if the plans haven’t been changed in ways that substantially cut benefits or increase costs for plan holders and notify plan holders that they have a grandfathered plan. To keep a job-based grandfathered plan, the employer must have continuously covered at least one person in the company since March 23, 2010.
Individual grandfathered plans. Individual grandfathered plans can’t newly enroll people after March 23, 2010, and have that new enrollment be considered a grandfathered policy. But insurance companies can continue to offer the grandfathered plans to people who were enrolled before that date. An insurance company can also decide to stop offering a grandfathered plan. If it does, it must provide notice 90 days before the plan ends and offer enrollees other available coverage options.
While the majority of stipulations in the ACA apply to all types of health insurance plans, grandfathered plans are allowed to maintain a lower standard of coverage as a political compromise towards meaningful reform. With their grandfathered status, these plans have a different set of requirements:
All health plans, including grandfathered plans, must:
It is important to understand the reasoning behind the changes made with the ACA and why our government had to do something to fix a broken system before it was too late. Before the ACA took effect, health insurers had a completely disproportionate advantage on the patient/insurer relationship. These healthcare reforms have been long overdue and were actually set up to help patients regain control from health insurers, no matter what other motives you might hear on Fox News. It is named the “Patient Protection” act, after all. You may remember some of the many ways health insurers ripped people off before the ACA:
Do any of these ideas sound fair to you? Obviously not. I think we can all agree that putting a stop to these devious insurance practices is a good thing for the healthcare industry, overall.
Despite the obvious benefits of having an ACA compliant plan, it does make sense for some people to continue coverage under a grandfathered plan. However, 3 out of 4 people with employer-based health insurance have an ACA compliant plan, along with almost everyone who is insured through the individual marketplace, so having a grandfathered insurance plan means you are going to face challenges and issues that do not apply to most of the population anymore, thanks to the ACA. Here are a few closing points to consider:
The majority of the advertisements, articles, new stories, and policy discussions that you see in the media regarding healthcare do not apply to you.
Your “preventive wellness exam” is not covered by your insurance. If you have a copay or deductible, those will still apply to this visit.
You do not have the right to appeal any decision by your insurer. This includes denials for prescriptions, imaging, and medical claims.
Patients Asked Thrice: Healthcare Insurance and Billing Q&A
This post is part of a series entitled “Patients Asked Thrice,” which is designed to answer questions I have received at least three times from our patients. The inspiration comes from the saying: “One’s an incident, two’s a coincidence, and three’s a pattern.” If three different people ask me the same thing, I can safely assume there is at least a fourth person out there who wants to know the answer.
If you have any other questions you would like me to address, or any follow up questions to this post, please include them in the comments section below. Thank you!
Instead of a bunch of words, simply posting this nice infographic from the CDC seems like a much more efficient way for me to tell you that diabetes is widespread concern that probably impacts someone you know. Please take a moment to at least skim some of the statistics and details about diabetes in the graphic below. On a side note, I may or may not have chosen this particular infographic because it fits in so nicely with our website’s color scheme.
If your diabetes is uncontrolled or believe you are at risk of developing diabetes, please contact your physician and schedule an appointment. If you are interested in learning more about how you can help yourself or someone you love, the American Diabetes Association offers a free program to people with type 2 diabetes called “Living With Type 2 Diabetes.”
The program, available in English and Spanish, provides information and offers free guidance to help people learn how to manage diabetes at regular intervals throughout the year-long. People can enroll into this free program by visiting diabetes.org/type2program, calling 1-800-DIABETES, or texting Type2 to 69866 to learn more about the program in English or Tipo2 to 69866 to learn more about the program in Spanish.
Topics and resources include:
Food, nutrition and recipes
Stress and emotions (see infographic below)
Peer support online and via phone
Support from the Association’s local office
Support from the Association’s National Call Center
Since we have added a wonderful Physician Assistant, Sarada Schossow, PA-C, to the practice, I thought it would be beneficial to our patients to outline what exactly a Physician Assistant is and how they are used in family practice. Here is the official definition of a Physician Assistant, according to the American Academy of Physician Assistants:
“Physician Assistants (PAs) are health care professionals who practice medicine with physician supervision. They conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and write prescriptions. They are often found in primary care practice — family medicine, internal medicine, pediatrics, and obstetrics and gynecology — but also work in many specialties, such as cardiology, emergency medicine, oncology, dermatology, gastroenterology, psychiatry, and in surgery and the surgical subspecialties.”
To better relate the concepts to patients, “A Patients Guide To Physician Assistants” created the “Patient’s Definition” of a Physician Assistant. This helps patients understand how care with a Physician Assistant will be seen from their perspective and has three basic categories that a Physician Assistant might fall under:
Physician representatives. Basically, a Physician Assistant is like a vice president that acts on behalf of their president (physician). PAs are competent and qualified healthcare providers that serve as representatives for their physician in doing most of the things for you that the doctor would. They are more of an associate than an assistant that helps to improve the efficacy of the physician’s practice. This means that if the doctor’s office that you visit has several Physician Assistants then you should see an overall decrease in wait time and an increase in time with the healthcare provider (PA or physician). It also means that you should be able to get appointments sooner because there are more healthcare providers to choose from.
Generalists. An important aspect to understand is that physician assistants are generalists. They are trained extensively in the same medical model that is used for doctors. Being a generalist allows them to have a wealth of knowledge in many areas of medicine. This means that they are able to approach your medical concerns from a whole-body perspective.
Patient Educators. One of the primary roles of the Physician Assistant is patient education. A patient that understands their illness and what they need to do to fix it will hopefully be able to prevent further illness. In other words, understanding is a key to wellness and prevention. PAs often have more time with the patient in order to educate them about their health.
At Family Care, Sarada Schossow, PA-C will be working directly with Dr. Sabrina Mentock and Dr. Elaina Lee to provide great continuity of care for our patients. Sarada Schossow, PA-C will allow Family Care to maintain the same personal level of care we currently show to each of our patients, while still having the ability to meet the growing demand for high quality medical care in our community.
To accommodate our growing volume of patients, current patients may be offered the chance to see Sarada Schossow, PA-C for certain types of appointments at times that may be more convenient or immediate than their current provider can arrange. These types of visits include:
When making a decision about whether to see a NP, PA, or MD most of the time it should not matter. The reason is that the NPs and PAs are also trained to know when something is beyond their ability or understanding. They should know when to refer you to a specialist or a physician. Any of the above practitioners know how to research and consult other practitioners in order to bring you the care you require. Doctors have more formal education and training to draw from, but aside from that there is much more variance in personality and individual dedication to the patient then in the type of provider you chose.
Check our Sarada’s introduction video below!
We are very excited to add Sarada Schossow, PA-C to our team and think she is a great fit with our practice. If you have any questions about the role she will play in providing great care for our patients, or would like to schedule an appointment, please contact our office!
This month, the Family Care blog will be featuring educational materials and information specifically for people living with diabetes. Our office has held free diabetes education classes for our patients for the past few years because we think it is necessary for patients to fully understand the disease to lower their health risks and the overall impact that diabetes has on their lives. November is designated as National Diabetes Education Month by the American Diabetes Association, so it is a great time to raise awareness of the challenges and help provide a better understanding of how to live with diabetes. The goal of the month, according to the American Diabetes Association:
The vision of the American Diabetes Association is a life free of diabetes and all of its burdens. Raising awareness of this ever-growing disease is one of the main efforts behind the mission of the Association. American Diabetes Month® (ADM) is an important element in this effort, with programs designed to focus the nation’s attention on the issues surrounding diabetes and the many people who are impacted by the disease.
Here are just a few of the recent statistics on diabetes:
Nearly 30 million children and adults in the United States have diabetes.
Another 86 million Americans have prediabetes and are at risk for developing type 2 diabetes.
The American Diabetes Association estimates that the total national cost of diagnosed diabetes in the United States is $245 billion.
Here is a great video of Republican Congressman Tom Reed discussing his personal reasons for recognizing and promoting National Diabetes Awareness Month in November and the reasons it is really a 365-day-per-year cause.
Throughout the month, we will have more content and specifics, so consider this an introduction to National Diabetes Awareness Month. For final takeaways, here are three messages on what National Diabetes Awareness Month is all about from the American Diabetes Association:
Eat Well, America! This year’s theme for American Diabetes Month in November.
Eating well means more than eating healthy. Eating well means savoring food that is delicious, nutritious and simple to prepare.
The American Diabetes Association will show people living with diabetes and others who want to lead a healthy lifestyle how to enjoy foods that are both delicious and nutritious.
We will inspire Americans to eat well by equipping them with tips for planning and preparing healthy meals on their own.
Diabetesforecast.org/adm and 1-800-DIABETES are the go-to resources offering meal planning, shopping tips, grocery lists, chef’s preparation secrets and delicious recipes.
The Association is leading the conversation that helps the nearly 30 million Americans living with diabetes and the 86 million Americans with prediabetes, as well as their loved ones, achieve health and wellness every single day.
Healthy Eating from Start to Finish. The Association will show Americans how to eat healthy from start to finish, without sacrificing flavor.
Every week in November, the Association will introduce recipes for every meal, including snacks and recipes for the holidays and other special occasions, when indulgences can present a challenge to your healthy eating plan.
The Association will include seasonal recipes and tips from noted cookbook authors and chefs to give Americans the extra boost to incorporate healthy eating into their everyday lives.
We will address the start-to-finish steps that empower people to put together a healthy meal that tastes good and is good for you and your family:
Planning and shopping tips will include mapping out a shopping trip, creating a shopping list and choosing budget-friendly ingredients.
Preparation and cooking tips will include tools and techniques that guarantee recipe success.
Plating and serving tips will guide people with simple steps to create a healthy, nutritious and appealing plate of food—whether at home or dining out.
Complete nutrition information for every recipe so that people can decide which dishes suit them best, based on their diabetes management plan and personal tastes.
Lunch Right with Every Bite! On National Healthy Lunch Day, the Association’s annual celebration of nutritious eating, we will spotlight what healthful, simple and enjoyable meals look like.
This year we’ll celebrate National Healthy Lunch Day on Nov.17, when we encourage everyone to “lunch right with every bite” and make better food choices to counter expanding waistlines, low energy and rising rates of type 2 diabetes and obesity-related illness. To start, let’s do lunch—a healthy lunch.
On this day, we will ask Americans to make or buy a healthy lunch and encourage employers and restaurants to provide healthy alternatives.
In addition, we’ll ask people to share their healthy lunch photos using the hashtag #MyHealthyLunch to create social media buzz. Our fans and followers will inspire their friends and family to make healthy lunch choices that best fit their lifestyle.