Ryan Mentock

Ryan Mentock is the practice manager of Family Care, PA. Ryan earned a BS in Business Management and Marketing from NC State University in 2006 and a MBA in Healthcare Administration from George Washington University in 2014. He enjoys reading articles on health insurance, analyzing the benefits and differences of health insurance plans, and working with health insurance companies to process claims. Yeah, we think he's weird, too. You can read more personal information about Ryan at www.ryanmentock.com.

What is a Deductible?

If your health insurance plan’s benefits involve some type of deductible, this article will help you understand the general terminology involved in your claims, how your charges are generated, the life cycle of a claim, and what to expect with this type of insurance plan. I have to answer a few other questions to get a fully detailed answer to “What is a deductible?” so I hope you don’t mind learning a few other things, as well! There will be too many words below already, so let’s get started!

TERMINOLOGY

I won’t waste space on the literal terms here because our in-network insurers do a good enough job with their dictionary definitions, here:

These definitions don’t add much context to a real-life claims situation, so I’ve included a familiar scenarios to practically interpret or understand the terminology:

  • Your PREMIUM is a set payment every month to your health insurance company for the right to have health insurance benefits. This is a fixed monthly expense that you owe for at least an entire year, regardless of how often you use healthcare services.
  • Your COPAY is a static number that applies to certain types of consultations, usually PCP, Specialist, Urgent Cares, and sometimes also Emergency visits. Regardless of the length of visit or topics discussed, you always will owe this amount every time you have a visit.
  • Your DEDUCTIBLE is a variable number that sets an amount of medical expenses that the patient must pay for diagnostic services prior to the insurance company beginning to cover a portion of the same services. Most plans, even plans with Copays, have at least a small deductible for lab services and prescriptions, while others have deductibles that apply to all services.
  • Your COINSURANCE is a variable percentage that applies to services incurred after your deductible has been met. If you owe 100% of services before your deductible, your coinsurance percentage is the amount you’ll owe after your deductible has been met. You’ll owe this percentage until you meet your Out-of-Pocket Maximum.
  • Your OUT-OF-POCKET MAXIMUM is the total amount of expenses you can possibly incur for approved medical services over an entire benefit period. Unless you have charges that are non-covered, out-of-network, or otherwise excluded from your benefits (eg. employers not allowing employees coverage for weight loss products), this is the most you’ll pay.

Now that the terms I’ll use below are out of the way, let’s learn more interesting things!

HOW ARE CHARGES GENERATED

This is another topic that I spent ~5,000 words on already in this article, so I’d suggest clicking through to the original article if you would like more details.

Essentially, the total charge is comprised from 5 factors:

  1. Insurance Company and In-Network Status. Are you in-network or out-of-network? You’ll pay more for out-of-network.
  2. Benefits on Insurance Plan. Do you have a copay-based plan, deductible-based plan, or cost-sharing plan? That will matter.
  3. Length and Content of Visit. Was it a quick, easy visit, or a long, complicated surgery? Longer, more involved visits are generally more expensive.
  4. Preventive or Diagnostic Coding. Was the visit preventive, or diagnostic? Preventive visits are usually free, diagnostic visits are more expensive.
  5. Services Provided. Did you also have labs, procedures, vaccines, etc. with your visit? Those will add costs.

For a frame of reference, here is a listing of our uninsured prices for most services at Family Care. Each insurance has their own fee schedule and rate of reimbursement, but these are good ranges to expect for commercial insurances.

THE LIFE CYCLE OF A HEALTH INSURANCE CLAIM

It is important to understand the timing and steps involved in a health insurance claim process so you do not waste more time than necessary dealing with your insurer. It’s already terrible enough to call, knowing you’ll spend longer than necessary listening to the most annoying hold music science can create, and it’s even worse if you call for no reason. Basically, insurance claims require patience because they intentionally delay things on purpose to drive you crazy, so knowing where you are at in the timeline can save you a lot of stress!

These are the basic steps involved in a claim. A workflow diagram would probably be appropriate here, but this will have to do for now:

  1. The Visit (Day 0). This is the interaction where you received a billable medical service. This is thing you did that requires payment to a medical provider. You were probably sick that day, so I hope you’re feeling better now!
  2. The Claim (Day 7-10). Family Care waits 7-10 days to submit a claim to a health insurance, but this delay is not universal. The main reason that our office waits is to allow patients time to ask and address any follow up questions to their visit under a single billable encounter. This policy is designed to reduce overall patient expense and eliminates one of the barriers to positive outcomes by encouraging the patient to ask questions they forgot or notify our staff immediately if a treatment is not going well.
  3. The Patient Response (Day 24-40). This period is when you will first receive a statement from your insurer after having a medical visit at our office. An Explanation of Benefits (EOB) will have the first determination of coverage and explains how your benefits applied to the medical service you received. There will be a Remark Code that represents the coverage determination reasoning – if you owe any money for a medical service, this remark will explain why. It will probably be short and incomplete, which is designed to either make you misunderstand the reason or give your insurer a lot of wiggle room to explain how they applied their reasoning. If you disagree with any coverage determination, this is your head-start on fixing the issue before you receive an invoice.
  4. The Provider Response (Day 31-47). About a week after you receive your EOB from your insurance, your provider receives their own statement, called an Explanation of Payment (EOP). This is when our office would find out that you owe us money. This is essentially identical to your EOB statement, but with many other patients on the same file and fewer specific details on each patient’s individual benefits.
  5. The Invoice (Day 38-54). Within a week of our office receiving the EOP for your claim, you will receive an electronic invoice for any balances due. This will be sent to the email address we have on file for you. You will receive reminders every two weeks and start to incur late fees after 90 days, unless you are actively appealing a denial.
  6. The Appeal (Day 45-90). Insurers will consider coverage appeals within the first 90 days after processing a claim. If you disagree with the benefits applied to your claim, you will need to file a formal appeal. The appeal process is different for all insurers, but it should be detailed on your EOB from Step #3. If you appeal, please notify our office and we can help guide you to avoid wasting more time making unnecessary appeal attempts.

As a general rule, insurers take about 30 days for absolutely every decision. If you file an appeal, there is almost no point in following up within 30 days of the submission. You will likely just be told that it is in process and to call back again, so skip that step and just be patient!

WHAT WILL ACTUALLY HAPPEN WHEN I VISIT MY PROVIDER

Terms and theories are great, but knowing what will actually happen to you is better! These are basic examples of three common situations – you owe a deductible balance that you agree with, you owe a deductible balance that you disagree with, or your claim is denied completely.

In all of these scenarios, you would have already received some type of medical care and have an insurance plan that features a deductible-based benefits plan.

  • Deductible Owed (Correct).
    • If you receive your EOB and agree with the balance due, you just need to pay your bill! If you already paid at the time of service, you’re probably done with the transaction. If you have not yet paid, you should expect a bill in about a week. This should be what happens >95% of the time.
  • Deductible Owed (Incorrect). 
    • If you receive your EOB and disagree with the balance due, there are two probable reasons why you disagree:
      • The EOB says you owe less than you were billed, or less than you already paid. There are a lot of reasons this could have happened, but as long as everything that was denied was a “covered service” it likely means you’ll end up with a credit or refund back from your provider. In most cases, you likely met your deductible either before or during the claim in question, when it is generally impossible to tell which claims insurers will process first. You’ll end up owing the same deductible amount, but the provider that you have to pay that amount to might change based on the timing of the claims.
      • The EOB says you owe more than you were billed, or more than you expected to owe. Similarly, there are also plenty of reasons this could have happened. There will be a remark code underneath the claim table that explains why something was denied or not paid. Depending on this reasoning, you can either review your coverage with your insurer or review the claim’s coding with your provider.
  • Claim is Denied. 
    • This is a light grey area where the total you might owe the provider is the same, but you are not getting credit towards your deductible.
      • eg. A denied service costs $100. Your provider bills you $100. If it was covered, your $5,000 deductible would then go down to $4,900, saving you $100 by the end of the year. If it was denied, the charges don’t get applied to your deductible and you still owe $100, so it’s basically like having a $5,100 deductible at that point. Obviously, that is worse.
    • In general, you’ll want all charges to be “approved,” even if you end up having to pay for them. The denial remark codes will explain your next possible steps towards getting a denied service reversed and approved.

When in doubt, contact your provider. We usually receive our version of your claim statements about a week after you do, so don’t freak out immediately when receiving a scary EOB. We can definitely get started on fixing issues before we receive our own statements, but just remember that we might not yet be aware something went wrong with your claim and will need a bit of time to help identify the issue. There is a general strategy to fixing every type of problem, but understanding what those problems look like and identifying how they happen should hopefully provide the tools necessary to defeat your insurance denial and receive the most from your insurance benefits.

2025-2026 Covid Vaccines

This page has information on how you can receive a 2025-2026 COVID vaccination at Family Care in Durham, NC. You do not need to be a current patient at our office, but current patients will have far less paperwork to complete before receiving the vaccine. Please review the details below and follow the instructions at the bottom if you’d like to schedule a vaccination.

Contact us if you have any questions!

VACCINE INFORMATION

Family Care will be offering two different types of COVID vaccinations – COMIRNATY and SPIKEVAX.

  • Patients above 5 years old may receive COMIRNATY.
  • Children between 6 months and 11 years old may receive SPIKEVAX.

Here are the specific details for each available vaccine. Unfortunately, we do not have the ability to order any other brands or manufacturers at this time.

Tradename: COMIRNATY
Proper Name: COVID-19 Vaccine, mRNA
Manufacturer: Pfizer BioNTech
Indication: COMIRNATY is a vaccine indicated for active immunization to prevent coronavirus disease 2019 (COVID 19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COMIRNATY is approved for use in individuals who are:

  • 65 years of age and older, or
  • 5 years through 64 years of age with at least one underlying condition that puts them at high risk for severe outcomes from COVID-19

Tradename: SPIKEVAX
Proper Name: COVID-19 Vaccine, mRNA
Manufacturer: Moderna
Indication: SPIKEVAX is a vaccine to protect you against COVID-19. SPIKEVAX is for people who are:

  • 65 years of age and older, or
  • 6 months through 64 years of age at high risk for severe COVID-19.

CRITERIA FOR VACCINATION

We are required to take a few extra confirmation steps this year, but our goal is to provide access to a COVID vaccine for anyone who wants one.

All patients must sign a form that confirms they have one of the following medical indications for vaccination.

  • Respiratory disease: Asthma, COPD, cystic fibrosis, interstitial lung disease, etc.
  • Metabolic & chronic diseases: Diabetes (type 1, type 2, gestational), obesity/overweight, chronic kidney/liver disease
  • Cardiovascular & cerebrovascular: Heart conditions (including congenital), stroke
  • Immunocompromised & disorders: Cancer, HIV, primary immunodeficiency, transplant recipients, immunosuppressant therapy
  • Neurologic & developmental: Down syndrome and other disabilities, dementia, Parkinson’s disease
  • Behavioral & lifestyle factors: Mental health disorders, physical inactivity, smoking, substance use disorders
  • Other conditions: Pregnancy, tuberculosis, sickle cell, thalassemia, etc.

This list is not comprehensive and your provider can help you identify other potential indications, if you are unsure. Current patients will have the benefit of already having medical records on file at our office to support these indications, while outside patients can self-select their covered indications.

COST & COVERAGE

In previous years, COVID vaccines have been considered preventive and covered at 100% with in-network coverage. As of September 4, 2025, we have not received any direct information to change that status, despite national headlines suggesting a threat to coverage. Because all insurers are different and it is always best to be sure of your benefits, we suggest contacting your insurer and asking about immunization benefits on your specific plan.

For Pfizer’s COMIRNATY, check your insurer’s benefits for the following CPT Code:

  • CPT Code 91320: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use in patients 12 years and older.

For Moderna’s SPIKEVAX, check your insurer’s benefits for the following CPT Code:

  • CPT Code 91321: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 25 mcg/0.25 mL dosage, for intramuscular use in patients 6 months–11 years old.

We expect your insurer to say these are covered preventive services and do not plan to bill any in-network patients up front, but we are preparing patients for the potential for changes depending on how insurers react to new guidelines.

If you are out-of-network, not a current patient at Family Care, or do not have insurance coverage, you can still receive the vaccine at these prices:

  • COMIRNATY (>5 Years Old): $150
  • SPIKEVAX (<5 Years Old): $135

If you are not a current patient, you will be asked to pay up front for the vaccine. We will file your vaccine with your insurer and refund your payment after ~30 days once your insurer processes the claim. Ideally, your insurer pays for the vaccine and we refund your payment by cancelling the original transaction a few weeks later.

SCHEDULING A 2025-26 COVID VACCINE

As of September 12, 2025, Family Care has started to receive our allocated shipments of 2025-2026 COVID Vaccines and we began administering vaccines to our patients on September 9. We are currently working through our existing waiting list, with full access to all patients available sometime in the next two weeks. Vaccines should become much more available before the end of September. 

If you are a current patient, we can administer the vaccine almost any time. We can add it to an upcoming appointment, or schedule a separate visit just for the vaccine.

If you are not a current patient, you will need to complete the same paperwork that a potential new patient would have to complete, then follow the same instructions above.

  • You do not need to fully transfer your care to our office, but we will need this information to confirm eligibility and allow us to provide medical care.
  • If you decide later (within 365 days) to transfer your primary care to our office, you’ll already have that part complete and the transfer process should go pretty quickly.

FAQ

Will you send a prescription to a pharmacy so I can receive the vaccine at another location?

No. Because we offer the vaccine at our office, and current requirements state that you will need a special appointment for the prescription to a pharmacy anyway, we will not send a prescription for a patient to receive the vaccine at another location.

Do I need to be a patient at Family Care to receive the COVID vaccine? 

No. You will need to complete the same paperwork necessary to establish care, but you will not be required to transfer care from your previous PCP to receive the vaccine.

Will my vaccine be covered by my insurance? 

Probably. This year’s coverage has been much more uncertain than most, but we are currently still expecting COVID vaccines to be considered preventive services by insurers. If we find out differently, this page will be updated.

What if I do not meet the criteria to receive the vaccine? 

The criteria is very broad, so you probably do meet the criteria already. Our staff can help you identify potential reasons or indications based on your medical history. If you do not meet criteria for any reason, you may have to pay for the vaccine, but you will still be allowed to receive it.

QUESTIONS?

We are hoping to receive more definitive answers from insurers and suppliers soon and will update this page with any new information. If you have any questions, please contact Ryan at 919-544-6461 or contact@familycarepa.com.

How are charges determined for primary care services?

How are charges determined for primary care services?

If you call to ask any medical office about prices, you’ll probably find that nobody is able to give you a direct answer. “How much will my visit cost?” will always be answered with some version of “it depends.” While that answer is true, a better answer might provide an estimate or range or an explanation about how those charges are generated. I’m hopeful that this article will be the best answer to that question you’ll ever receive.

This is a breakdown of every factor that goes into determining how much you are charged for a certain primary care medical service. These examples are related to primary care charges, but should translate well to specialist and urgent care charges, and at least provide a baseline of understanding for hospital-based charges.

  1. Insurance Company and In-Network Status.
  2. Benefits on Insurance Plan.
  3. Length and Content of Visit.
  4. Preventive or Diagnostic Coding.
  5. Services Provided.

INSURANCE COMPANY AND IN-NETWORK STATUS

As often as possible, you’ll want to visit providers that are “in-network” with your insurance. Being in-network means your provider has a contract in place with your insurance company to accept payment from your insurer and help you receive the benefits under your insurance plan.

Part of signing a contract with an insurer is agreeing to a “contracted rate” for medical services. This rate is determined through negotiations between the insurer and your provider, with some providers able to make deals for higher pay for the same services. Larger practices and hospital-affiliates can use their scale to negotiate better terms on their deals. Basically, they can get paid more for the same service because the threat of the large hospital leaving the network is greater than the threat of a small, independent practice leaving the network.

  1. Family Care receives roughly $70 for a 99213 from Aetna, one of our most used office visit codes. The closest large hospital-based primary care to our office receives ~$110 for the same code. If you have a deductible to meet for primary care services, you’ll be paying $70 at an independent facility or $110 to the large hospital for the same type of visit.

This contracted rate also varies significantly from one insurer to the other. Going back to CPT Code 99213, here is a range of rounded prices from various insurers at Family Care for the same code:

CPT Aetna BCBS Cigna United Healthcare
99213 $70 $85 $75 $70

BCBS allows higher reimbursement for the same service than most other insurers, mostly because they also have stricter standards for quality and claim management in their provider networks and provide a lot better coverage for services than other plans. However, two people that received the same service can be charged different amounts, based on the contracted rate that your provider has in place with each insurer.

If you go out-of-network, the provider is technically allowed to charge you whatever they want! There are a few requirements for limiting charges, but you’re essentially operating outside of any contracts and subject to whatever rules the provider has in place. At Family Care, we offer uninsured or out-of-network patients the same rate as our lowest paying insurer. At large hospital facilities, they’ll double the price and act like they’re doing you a favor by giving you a 10% discount.

Summary: In-network providers sign contracts to follow rules that protect the patient and allow you to access your insurance benefits, so stay in-network. Larger facilities cost more, and contracted rates vary based on the insurance company.

BENEFITS ON INSURANCE PLAN

We just covered an aspect of the charges that is beyond your control – the negotiated rate between your insurer and your provider. This section is related to how charges are assigned between the two parties that will pay for your healthcare expenses – either the patient or the insurer. The final answer is determined based on the benefits on your insurance plan and the contract you signed with your insurer.

These days, there are two main types of plans you can decide from:

  • PPO / “Copay” Plan: This plan has higher premiums, but you pay less when you need care.
  • Deductible-Based Plan: This plan has lower premiums, but you pay more when you need care.

There are lots of options in-between these two choices, but we’re going to be over 5000 words with this article already and the exceptions could fill a book, so we’re just going to simplify things and focus on these two most common options.

If you have a Copayment for primary care services, your costs are essentially fixed. Every time you visit your primary care provider, you’ll likely owe a $X copayment. You’ll likely have a deductible for non-standard services, labs, and procedures (eg. minor surgeries, in-house diagnostic tests, EKGs, etc.), but you’ll know to expect a $X copay almost every time you seek care. Because those types of plans are fairly easy to understand and you don’t really need to worry much about factors that go into the total cost of your visit (because you only need to pay your copay, regardless of the amount of total charges), this article will be focused on deductible-based plans.

Under a Deductible-based plan, you pay 100% of all non-preventive medical charges until you have met your deductible. After meeting whatever deductible amount you have on your plan, your responsibility for future charges drops to a Coinsurance Percentage, usually around 10%-20% of all charges. This means you still have a variable rate of responsibility after your deductible, but it is calculated at a much lower amount. You will continue paying variable-rate bills at that lower percentage until you have met your Out-Of-Pocket Maximum (OOPM) for the year.

The benefit of a deductible-based plan is usually seen in your monthly premiums. Plans that cover more expenses (ie. Copay plans) are guaranteed to have higher fixed costs through monthly premiums, while plans that cover fewer expenses (ie. Deductible plans) are guaranteed to have higher variable costs based on usage. Here is a quick example of a three-month period for two different patients receiving the same care – one with a copay plan and one with a deductible plan.

Patient Plan Type Premium Visit #1 Visit #2 Visit #3 3-Month Total
Alice Copayment $700 $25 $25 $25 $2175
Betty Deductible $350 $125 $75 $225 $1475

In this example, Betty had to pay $425 more to their provider for the same services that Alice received for only $75. However, Alice also paid the insurance company $2100, while Betty only paid the insurance company $1050 in the same period. Overall, Betty owed more to the provider when they sought treatment and medical care, but still saved a significant amount in total out-of-pocket expenses by having a lower fixed premium expense each month.

As I outlined in a previous BCBS State Health Plan article, there is always a point of usage where both plans match overall expenses equally. In general, the more health problems you have, the more you should want higher premiums and lower expenses for receiving care. You don’t want an unexpected cost to be the reason you don’t receive treatment, or a reason to avoid seeking the care you need. The promise of a set expense when receiving care is valuable and lowers barriers to treatment for many people who have chronic or complicated conditions.

On the flip side, if you do not have many health problems and don’t expect to require healthcare services often, you’ll want to save your fixed expenses each month and just save money until you need care. If you save $350 per month on your premiums, but must pay an extra $100 every three months to your provider, you’ll still be way ahead on costs, overall.

The trick is to figure out which side of the chart you’ll end up on and try to match your coverage accordingly. Every insurance plan can benefit someone, but the hard part is finding the insurance plan that benefits you, specifically.

Summary: The benefits on your insurance plan determine what percentage of the total charges you’ll be responsible for paying at each visit. Better coverage means higher monthly premiums, but lower expenses when you seek care.

LENGTH AND CONTENT OF VISIT

We’ve covered the “Insurer-Provider” and “Insurer-Patient” relationships that impact payment responsibilities, so this one is basically the “Provider-Patient” section.

For any service-based industry, time is money. If you hire a mechanic, plumber, landscaper, contractor, lawyer, or accountant, it is generally accepted that these professionals charge by the hour. The same is true for medical providers, with a few exceptions and requirements.

Primary care services fall under three main categories:

  • Office Visits. Any discussion or consultation with a medical provider that results in the treatment, diagnosis, or management of a patient’s problem, concern, or illness.
  • Preventive Services. Standardized screening services, as determined by the patient’s age, gender, risk factors, and family history. These are essentially “scripted” visits and do not necessarily consider a patient’s individual medical history when being performed.
  • Lab Services. Samples and specimens collected to obtain preventive or diagnostic lab results.

For Office Visits, you will be billed based on time and complexity of the visit. Short, simple appointments are cheaper than long, complicated appointments. Family Care utilizes coding calculators to provide accurate charges for services, which follows the current AMA recommendations and requirements for medical decision making outlined here. The entire table is a great resource, but here is a quick summary of our 4 most common codes, the non-preventive codes used for standard consults/problems/issues:

  • 99212: 10-19 minutes, minimal complexity, minimal risk
  • 99213: 20-29 minutes, low complexity, low risk
  • 99214: 30-39 minutes, moderate complexity, moderate risk
  • 99215: 40-54 minutes, high complexity, high risk

In general, your visit only needs to hit at least 1 of the 3 factors to reach each threshold. This is why time is the simplest way to understand the charges, but also why a short visit might end up being charged at a higher amount. For example, a 15-minute visit about acne would be a 99212, while a 15-minute visit about anxiety and depression might be a 99214. This difference is mostly related to the extra requirements we have from insurers and resources we must allocate to manage the higher complexity problems.

Keep in mind that the times listed are also not the amount of face-to-face time you see the provider, but the amount of time the provider takes to see you. Here is the definition of “time,” according to the AAFP:

The definition of time consists of the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician or other QHP in care of the patient on the date of the encounter. It includes activities such as:

  • Preparing to see the patient (e.g., review of tests);
  • Obtaining and/or reviewing separately obtained history;
  • Ordering medications, tests or procedures;
  • Documenting clinical information in the electronic health record (EHR) or other records; and
  • Communicating with the patient, family, and/or caregiver(s).

For most visits, especially chronic conditions, your provider spends at least 5 minutes before your visit reviewing your records, results, and preparing to speak with the patient about whatever problems you have presented with at your visit. After your visit, your provider will also spend at least 5 minutes (usually more) documenting your visit, sending prescriptions, writing referrals, and coordinating your care with specialists. Because of this, a 99212 is uncommon. Most visits take 15-20 minutes of face-to-face time and 5-10 minutes of prep / post time from your provider. It is rare that an entire problem can be introduced, diagnosed, addressed, and treated within just 19 minutes, but it does happen!

At Family Care, regular office visits are charged at a 99212 (shortest) or 99215 (longest) rate about 10% of the time each, at the 99213 or 99214 rate about 40% of the time each, so a 99213 or 99214 should be expected for most visits.

Summary: You are basically paying by the hour and complicated conditions require more time. Charges are generated by the provider’s total time spent preparing, administering, and documenting your healthcare, not just the face-to-face time spent with your provider. A short, simple visit will have lower billable charges than a long, complicated visit.

PREVENTIVE OR DIAGNOSTIC CODING

Instead of a “relationship” between the provider, patient, or insurer, coding guidelines are more of a regulation that providers must follow based on CDC and World Health Organization (WHO) guidelines. There are two codes that combine to determine the codes used for each visit – CPT Codes and ICD10 Codes. Each one of these codes has the potential to be used to represent preventive services or diagnostic services, which greatly change the likelihood of a particular service being paid for by an insurance company.

Preventive services are essentially screenings to identify any problems and make sure you are up-to-date on healthcare guidelines based on your age, gender, and risk factors (eg. Are you due for your mammogram?). I wrote a few thousand words about preventives services here, so I won’t go into that topic much here.

Diagnostic services essentially cover everything else, but can briefly be summarized as things that are related to health problems or concerns that are unique to an individual (eg. Knee pain, influenza, high blood pressure, etc.). Outside of your annual preventive exam and services specifically outlined as preventive under your insurance benefits, you should start with the default expectation that all services will be considered “diagnostic.”

CPT Codes are the answer to “what service did I have?” Each CPT code represents a different type of service that fits within the same standards for medical care and decision making. Every unique service is represented by a unique CPT code, with some groups of codes representing a service that is classified as “preventive.” Here are a few examples of how a CPT code works:

  • Example A: Alice and Betty both see a doctor for an in-person visit and get an EKG performed during their exam. Both patients will have CPT 93000 added to their charges.
  • Example B: Chris and Dave both have a lipid panel drawn to check their cholesterol. Both patients will be charged for CPT 80061 by the laboratory.

ICD-10 Codes are the answer to “why did I have that service?” Each ICD code represents the problem, issue, illness, or concern that explain why you sought medical treatment. Like CPT codes, ICD codes also have groups that represent a preventive or diagnostic service. The new ICD-10 system uses fun categories based on the types of problems each category represents (eg. If an ICD-10 code starts with the letter Z, it is considered preventive).

Now that we know what CPT codes and ICD-10 codes are, and the difference between preventive and diagnostic, I can explain how the relationship between these two codes ultimately determines your benefits. This table explains the possible outcomes:

  Preventive ICD-10 Code Diagnostic ICD-10 Code
Preventive CPT Code Preventive Diagnostic
Diagnostic CPT Code Diagnostic Diagnostic
  • If both the CPT and ICD are Preventive, the claim will be considered Preventive.
  • If either the CPT or ICD are Preventive, the claim will be considered Diagnostic.

Going back to the previous examples, here is what would happen with different scenarios.

  • Example A: Alice did not have any heart problems at her visit, but received an EKG because her insurance allows one screening EKG after she turns 65 years old. Betty has had two heart attacks in the past 5 years and was ordered to get an EKG by her cardiologist because he noticed a murmur. Alice’s EKG will be paired with a preventive ICD-10 code and be considered a preventive service. Betty’s EKG will be paired with a diagnostic ICD-10 code and be considered a diagnostic service.
  • Example B: Chris has never had problems with cholesterol before and had his lipids checked as part of a routine annual wellness exam. Dave has a long history of cholesterol issues and was recently admitted to the hospital for heart failure. Chris’s lipid panel will be paired with a preventive ICD-10 code and be considered a preventive service. Dave’s lipid panel will be paired with a diagnostic ICD-10 code and be considered a diagnostic service.

The same service is provided, but the pairing to designate “preventive” or “diagnostic” will ultimately determine which class of benefits the charges are considered under.

Summary: CPT codes are the “What” and ICD-10 codes are the “Why” for any insurance claim. If both are preventive, the claim will be preventive. If one is diagnostic, the claim will be diagnostic. The same service can be considered either preventive or diagnostic, depending on why it was ordered.

SERVICES PROVIDED

We’re close to 3000 words already, so we’re lucky that this section is short and easy! If you have something done, you’ll be charged for it. If you don’t have something done, you won’t be charged for it. Simple!

To make this short section helpful, here are a few examples:

  • Visit A: 20-minute visit, only. $100.
  • Visit B: 20-minute visit, plus a flu test. $125.
  • Visit C: 20-minute visit, plus a flu test, plus a vaccine. $225.

The more things you have done, the more you will be charged. Think of it sort of like a restaurant menu and ordering different items, except those items are different services.

In primary care billing, there are only about 25 codes that are used with any frequency. Things can get complicated with hospital services, visits that require multiple providers or specialties, or when any drugs are administered, but thankfully we can pretty much list every code we’ve used more than once per year.

These codes are our basic uninsured rates, so they do not consider the network contracted rates that are described in the first section of this article. Generally, these listed prices are within 10% of our average, so it can be used as a good estimate.

Summary: There is a separate fee for every service, test, vaccine, or treatment you receive. If you have more things done, you will pay more in total.

FINAL SUMMARY

Medical billing can be complicated, but there are some basic concepts that should help you work out any problems or discrepancies and help you predict your cost of care. If you understand your insurance benefits and how your charges are generated, you shouldn’t be too surprised by any one charge. Understanding these concepts will also help you speak with your insurer or provider to dispute any discrepancies or file an appeal. Getting guaranteed medical billing information up front is difficult for a lot of reasons, but I hope this information helps establish an estimate for charges under any type of insurance plan and provides a framework for patients to understand their coverage and charges better.

If you are a patient at Family Care and have any questions about this information, please contact Ryan!

Family Care is a Non-Participating Provider with Medicare. What does that mean?

What happens when you visit a Non-Participating Provider with Medicare?

Family Care is a non-participating provider with Medicare, which basically means we do not accept assignment (ie. receive money) from any Medicare program. This is a brief summary of what that means from Medicare.gov:

  • You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.

  • They can’t charge you for submitting a claim. If they do not submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE.

  • They can charge you more than the Medicare-approved amount, but there is a limit called “the limiting charge “. The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.

While most non-participating providers will force you to leave the practice, we allow new Medicare patients to remain at our practice because we do not think insurance companies, even Medicare, should dictate who you are allowed to see as your primary care provider. Family Care will attempt to make the process simple, but there are some unavoidable downsides you should expect when considering remaining as patient and visit a non-participating Medicare provider:

  • You will be required to pay up front for your visits. You pay us, we file your claim, Medicare pays you. These claims are included in your Quarterly Beneficiary Notice and any payments for approved services will be made directly to you, not to our office.
  • You will need to wait 1-3 months for reimbursement. The full claims process usually takes 4-6 weeks, but Medicare should reimburse you ~70-90% of the amount you paid.
    • If you pay us $100, we expect you to receive a ~$80 check from Medicare.
  • Most services will cost ~10%-15% more than normal. An average Medicare visit costs $100, so you can expect to pay $7-$12 more per visit every time you have an appointment.
    • If a service costs $100, you would probably only owe ~$10 at a participating provider, but you would end up owing ~$20 at Family Care.

We want what is best for our patients, even if that means helping them transition care to another primary care provider. We understand that this arrangement may not work for all patients and they might prefer a simpler process with an in-network / participating provider, instead. We are extremely grateful that many of our patients like our providers so much that they are willing to deal with these changes and remain patients at our practice. If you do wish to change providers, we can easily transfer your records to help make a smooth transition to a new provider.

To give you some positive news, here are a few reasons why you might want to stay as a patient, even though we do not accept your new Medicare insurance:

  • We still file your claims with Medicare. You should not have to do any paperwork to submit your claims; you will only need to notify us in the event of a denial or non-payment so we can fix the issue.
  • We will help you read your Beneficiary Notices. Every three months, Medicare will send you a summary of all charges incurred during the previous period. If you have any questions, Ryan would be glad to review the document with you to help you understand what happened.
  • Our lab accepts Medicare. You will not have any additional costs or problems associated with a non-participating provider status for all lab samples and testing. These services would be processed as in-network with your Medicare plan and would be the same anywhere you go.
  • Your Welcome to Medicare Exam is still covered. This initial screening within the first six months of your enrollment date has the same level of benefits for participating or non-participating providers.
  • You can keep your provider. If you’ve been with us for a long time, we will be sad to see you leave!

We understand that learning the Medicare process can be like learning a new language. Their statements, forms, and processes are quite different than most commercial insurances, so there will be a learning process in the beginning regardless of where you go for care. You will experience many changes just because you are on Medicare, and then we add more exceptions to the rules because we are non-participating, so it can be a confusing process at first. If you remain as a patient, our hope is that we can make the process easy and clear. We will help guide you through the process so you are an expert on your Medicare coverage after you first couple of visits.

If you have any questions at any point during your transition, please ask Ryan!

Self-Pay Lab Pricing

If you are reading this, you were probably directed by our staff to review our policies for self-pay / uninsured pricing discounts on laboratory services. We hope this will be a quick, easy-to-understand guide on how we can get the best price on your lab costs, regardless of your insurance coverage. There are a lot of ways your labs can be billed and the method that ends up costing you the least amount of money can vary based on your coverage, the tests you have done, the reasons you’re getting tested, and when you are able to make a payment. This should cover the majority of scenarios, but please let us know if you have any specific questions!

Three Ways Labs are Billed

  1. Through an Insurance Company. If you have coverage, the lab submits diagnosis codes and procedure codes to your insurance and asks them to pay for your testing. Labs that are “covered” by your insurance will be payable at the insurance’s “Allowed Rate.” The Allowed Rate is a contracted price agreement between the lab company and your insurance, where your insurer agrees to pay the lab $X in exchange for performing a specific test.
    • If the test is considered preventive, or if you have already met your out-of-pocket maximum for labs, your insurance will pay the Allowed Amount.
      • Note: Your test will not be considered preventive if it is ordered outside of your Annual Wellness Exam. Preventive tests still need to be ordered for preventive reasons to be covered. (eg. you can order a Lipid Panel as a yearly cholesterol check or as a follow-up on hyperlipidemia. One would be preventive, the other is diagnostic, even though it is the same test.)
    • If you have a lab deductible to meet, you will be responsible for paying the lab the Allowed Rate amount.
    • If you have met your deductible, but not your out-of-pocket maximum, you will probably owe a coinsurance rate, usually 10-20% of the Allowed Amount.
    • If your insurance does not cover a test, the Allowed Amount does not apply and the lab will bill you the Charged Amount.
  2. Directly to Patient using the Lab Company’s uninsured pricing. If you don’t have insurance coverage or if your insurance doesn’t cover a test, the lab will bill you their full Charged Amount. If you agree to set up a payment plan with the lab, they will apply Uninsured Pricing discounts, which are usually about 40% lower than their Charged Amount.
  3. Directly to Patient through Family Care’s client pricing. If you know in advance that a test will not be covered by an insurance, the best method is to pay up front to Family Care at the time of service. The lab charges our office a Client Price, which is even lower than the Uninsured Pricing Discount.

As a general rule, if the Charged Amount for a certain test is $100:

  • the Lab’s Discounted Uninsured Price will be $50
  • the Family Care Client Price will be $20
  • the Insurer’s Allowed Amount will be $10

I will be using these amounts in all examples, but please note that the rates vary significantly by test. This pricing structure is simplified, but the ratios are pretty consistent. Our discount with the lab is primarily based on volume, so specialty tests or tests that are not ordered frequently have less of a difference than standard, routine tests that we order often. If there is anything that is not listed in our Self Pay Prices, we can provide a quote for you within a day or two.

The Problems

Unfortunately, it is not always as simple as “just give me the lowest number.” The company you pay, when you pay them, and how they filed with an insurance all matter when determining how a claim can be processed with the lowest out-of-pocket cost. There are a lot of situations where you can predict denials and uncovered expenses, but there is almost no way to avoid that potential entirely. Here are the problems and dead-ends you might experience while trying to navigate this system.

  • If your insurance denies one test, but approves the others, we cannot just adjust the price of the one denied test. Often, someone will get a panel of ~5 different tests run through their insurance. Each test will be billed for $100, with 4 of them being covered by an insurance, discounted to the Allowed Rate, and applied to a deductible, so that the patient owes ~$10 per test. However, the 5th test was denied completely, leaving the patient with $100 owed for the one denied test + $40 owed for the four approved tests, for a $140 total bill.
    • Once the claim goes through an insurance and they accept at least some part of the claim, we can no longer offer Client Rate pricing for any of the tests on the claim. Even though our rate for the denied test would have been only $20, we would have to switch the entire order over to a client rate, so you’d end up paying $20 x 5 tests, or $100, total. It could still technically save you money, but you’d be wasting coverage for four of the tests and not optimizing your final rates.
    • If we were aware up front that the 5th test would be denied in this scenario (usually when someone is repeating a test that they had problems with before), we could split the tests into separate orders and then have you pay $20 at the time of service for the 5th test. We wouldn’t even attempt to seek insurance coverage for that test, and then try to process the other 4 tests normally through your insurance.
  • If your insurance approves all tests, that is likely the best rate you can receive. If your insurance covers a test, but applies it to a deductible, the insurer’s Allowed Rate will be lower than any Client Price we can offer. Having something applied to a deductible unexpectedly isn’t ideal, but there are no options to further reduce the price if it was an accepted test. Unless you can convince the insurer to cover the test as preventive, the deductible rate is probably your best price.
  • You need to request any discount through the lab. If something is denied, the lab will automatically bill you the full Charged Amount. To qualify for any type of discount program, you need to request it. We try to provide the lowest prices to our patients up front so we don’t run into any problems with the lab’s billing, but we cannot make any changes to your lab bill without your request. If the claim has advanced to the point where you owe the lab a large amount of money, you will need to follow the steps to resolve a lab bill listed here.
  • You generally need to pay up front. There are a lot more options available if you make your payment up front. If we are trying to fix a denied claim or adjust a date of service from more than 7 days ago, we may be limited in how we can proceed. This does not mean trying is worthless if you didn’t know this up front, but the lab is generally a lot more flexible before the test has been performed.

How to Get the Lowest Cost for Labs

If you have insurance…

  • Verify your coverage for preventive services. At your annual wellness exam, request the tests that your insurance considers preventive and ask that they be included as part of your annual wellness exam. If you want a test that is not considered preventive, or if you attempt to have these tests done outside of your annual wellness visit, you will likely owe a lab deductible amount for the tests. Still, this allowed rate will be the lowest price option available to you.
  • Verify if a test is considered a “Covered Service” under your plan. The term COVERED and PAID are not the same – your insurance can say they “cover” a test, but that just means that they will allow your benefits to apply to the claim. If you have a lab deductible to meet, you will still end up paying out-of-pocket for “covered” services. If a test is not considered “covered,” you will not receive any type of Allowed Amount insurance discount and be responsible for the entire Charged Amount.
    • Remember to clarify the slight distinction between these terms when you speak with an insurer:
      • COVERED / APPROVED / ALLOWED – These terms mean that it is an available service on your plan. Your plan will approve a claim for this service and apply your plan’s benefits towards potential payment. It DOES NOT mean that it will be paid by your insurance. If you have a deductible, you will still owe the Allowed Amount for a “covered” service.
      • PAID – This is what you’re going for. You want your insurance to actually PAY for a service, not just give you the right to pay for the service at a lower rate. Discounts are nice and all, but $0 out-of-pocket is better!
        • You want to ask “Is this lab paid as preventive?” rather than “Is this lab covered as preventive?”
  • Verify the diagnosis codes that your provider will use to file your claim. If the code starts with a Z, your provider is ordering it as preventive. If it starts with anything else, your provider is ordering the test as diagnostic. Services considered “preventive” by your insurer will likely be Paid, if the provider bills them as preventive. Non-preventive tests will only be Covered if a non-preventive diagnosis code is used, but you will most likely owe some type of lab deductible for the tests.

If you don’t have insurance…

  • If you don’t have insurance at all, there is nothing really to consider. There is no hope for coverage, so you just want the lowest rate possible up front. That would usually be the Family Care Client Price, since we’re able to pass along a better deal than the lab will give you.
  • You should request a Client Price up front and make payment to Family Care prior to having your labs drawn for the easiest process.
    • If you pay up front for the lab and still receive a bill from Quest Diagnostics, please do not pay this bill and notify Family Care. We will resolve the error.
  • For full disclosure, we earn roughly $5 per test billed at our Client Price. For example, if we bill you $20 for a test, our true cost to the lab on your behalf is probably around $15. We add this fee for the work necessary to process these changes and also allow for some of the risk involved in taking on unsecured patient debt. Considering the lab likely billed you around $50 for the same test, we feel like this is a good compromise for everyone and helps reduce costs significantly for uninsured patients.

Our goal is to reduce patient costs at all levels. Focusing on proper lab billing procedures is the easiest method for significant, easy-to-fix changes that result in lower out-of-pocket expenses for our patients. When in doubt, contact Ryan with your situation and we can provide customized advice to help make sure you receive the best price.

Things To Know Before You Sign Up for Health Insurance

This post will provide a summary of the most important things to learn before you sign up for health insurance. There are several decisions to make, mostly based on when you are signing up and what types of networks or coverage you’re willing to accept. We will do a quick review of the reasons to obtain health insurance, the different types of health insurance plans available, the most common methods for obtaining insurance, and information on how to sign up for health insurance on Healthcare.gov. If you have questions, please contact Ryan!

Why Should I Get Health Insurance?

There are a lot of reasons to have health insurance, even if you are healthy or have a high deductible plan that you think will never pay for anything. Outside of the Marketplace, you should be skeptical of unusually low-premiums, because they may not provide any real benefit. Within the Marketplace, however, you can be assured that certain things will always be covered. These are some of the benefits that having any level of in-network insurance provides to members.

  • Preventive Services – While not quite as simple as “all preventive things are covered for free,” the vast majority of the screenings, wellness exams, and preventive testing you’ll need based on your age will be covered and paid for, 100%. You can easily take advantage of a few monthly premiums-worth of free preventive services, if you use them all each year.
  • Vaccines – Vaccines can basically range from $30 to $350 (mostly ~$60-$150), depending on the vaccine. The majority of these are 100% covered under most commercial insurer’s preventive coverage, with no cost to you. If you are due for any vaccinations, you should get up to date while you are insured.
  • Network Discounts – For most services, insurance companies have negotiated discounted rates that are passed on to their members. This is most obvious in the cost of common lab tests. Lab companies generally charge 10x-100x the actual cost of running a test, just to see how much an insurance company will pay. If you don’t have insurance, you may end up on the hook for a very large number that could have been drastically reduced. Even if the total gets applied to your high deductible, the rates are insanely lower just because you have insurance.
    • Note: If you are a patient at Family Care and you receive an unexpected bill from our lab, please read this article, then contact Ryan. We can often reduce your bill by at least 50% for any denied test that was drawn at our facility. Please do not pay any bill that doesn’t match your Explanation of Benefits until you’ve reviewed it with our office and give us a chance to help you fix the problem! 
  • Peace of Mind – Not to make this depressing, but what would happen if you didn’t have insurance and got hit by a bus tomorrow? High-deductible plans seem worthless if you just go to the doctor a few times a year and your plan never has to pay anything out, but they do provide an out-of-pocket maximum that is designed to prevent anyone from ever going bankrupt due to medical debt.
    • Without insurance, you’re paying $1,000 per hour (or more) for the duration of your 2-week / 336-hour / $350,000 visit to the ICU that saved your life after the accident.
    • In North Carolina, the premiums for the lowest tier plan on Healthcare.gov averages $365 / month. Even in this extreme bus accident example, that means you’d have a maximum of $14,380 in premiums and out-of-pocket expenses. That would be the same number if you had $15,000 in healthcare expenses or $10 million in healthcare expenses. The benefit to these plans is on the high end, which is why they’re called “Catastrophic” plans. In a worst-case scenario, you’d owe $14,380…not $10 million.
    • It doesn’t have to be as drastic as this example, either. A single visit to the Emergency Room can easily meet a $5,000 deductible and make the rest of the year’s healthcare extremely affordable. You should consider the likelihood that you’ll need any type of emergency care or surgical procedure in the next year, and how much risk you’re willing to take if you don’t obtain coverage. This cap on total liability is often overlooked by many new to insurance, so I thought this example would help provide that perspective.

Types of Health Insurance Plans

The first step is deciding what type of health insurance you are looking for in the first place. There are a few different broad categories of healthcare plans – here is a basic description of each type of coverage, each with its own cost/benefit analysis. You may decide that several of these options are potential candidates, but it helps to narrow the search as much as possible at this stage.

  • Health Maintenance Organization (HMO). Very limited network, no real choice in providers, the HMO manages all aspects of your healthcare for you. Usually cheap and efficient (because you don’t have any options or choices), this is a good plan if your provider already accepts the HMO or if you don’t have a real preference on the “who, where, when” parts of healthcare.
  • Preferred Provider Organization (PPO). Access to a wide network of providers that have accepted your insurer’s rates and contracted as “in-network” providers. Easiest access to specialists, you don’t need to select a primary care provider (PCP), and generally the type of plan that makes you feel like insurance companies aren’t completely evil because they give you a lot of freedom and have great benefits. You’ll pay a bit more to go outside your network, but some of your benefits will at least still apply. These are usually the most expensive, so you generally pay extra for the luxury of not having your health insurance company make certain decisions for you.
  • Exclusive Provider Organizations (EPOs). Similar access to a network of “in-network” providers as PPOs, but a much smaller network and much harsher penalties if you leave the network. Generally, you are not eligible for any benefits for out-of-network expenses, excepting emergency situations. You must elect a specific PCP and only see that provider to qualify for primary care benefits for anything. You don’t need a referral to see a specialist, but you still need to make sure the specialist is in your network. If you are very careful with your network of providers, this can be a lower cost option to PPOs with similar benefits.
  • Point-of-Service Plans (POS). This combines features of the HMO and the PPO plans. You must elect a PCP and only visit that PCP to qualify for full benefits, and you will need a referral from your PCP for all specialist appointments. These plans are usually very easy to determine out-of-pocket expenses, as they usually have simple co-payments based on the type of provider. They will have very low deductibles, if any, but higher premiums. While you only receive full benefits with in-network providers, these plans do offer some limited coverage for out-of-network visits.
  • High-Deductible Health Plans (HDHP) & Health Savings Accounts (HSA). These plans require you to pay for almost every health care expense you have each year, up to the limit of your deductible amount. The definition of “High” deductibles starts at $1,350 with no real cap, but generally a $10,000 deductible is the highest you’ll see and most deductibles are around $2,500. These plans generally still have coverage for screenings, preventive services, and vaccines, so you can still obtain these services for free before you’ve met your deductible. These have the lowest premiums, by far, so you’re basically saving the guaranteed payment each month in exchange for the out-of-pocket payment at your provider when you need care. Don’t be shocked when you have a large bill at an appointment – remember how much lower your monthly premiums are and take that into account. Here is a breakdown on how to weigh the differences between “high premium / low out-of-pocket plans” and “low premium / high out-of-pocket” plans. These are great if you expect to never use your healthcare, or if you get hit by a bus and end up in the hospital for months. Once you meet your maximums, get the best bang-for-your-buck that you can on the “free” healthcare after your deductible and out-of-pocket maximums have been met. As long as you don’t “almost” meet your deductible, these are a good value.

Where Can I Get Coverage?

Now that you know what type of coverage you’re willing to accept, you’ll need to actually sign up for an insurance plan. In the United States, there are 7 basic methods of obtaining health insurance.

  • Medicare. Coverage granted by the Federal Government to citizens automatically once they turn 65 years old, or earlier if you are permanently disabled or have end-stage renal disease.
  • Medicaid. Coverage awarded and administered by individual State Governments to low-income citizens that meet certain eligibility requirements.
  • Military. Coverage earned by soldiers in the Federal Army and State Reserves. Generally, benefits are only in-network through the Veterans Administration (VA), but they do provide good out-of-network coverage if you’re willing to do paperwork.
  • Employers. Coverage provided through an employer’s group benefit plan. Plans vary widely by employer and usually involve some portion of the premiums being deducted from the employee’s earnings. Contact your company’s HR department to determine their enrollment process.
    • COBRA. This is special exception through Federal Law that provides a bridge to a new plan after you lose employer-sponsored coverage to avoid a lapse in coverage, usually involving the employee to take on a higher premium payment during their coverage period. If you’re on COBRA, you likely lost your job, so I’m sorry. You’ll get a new one soon! I believe in you!
  • Commercial Insurers. Coverage purchased directly through a health insurance company for yourself or your own immediate family. This includes companies like Blue Cross Blue Shield, Aetna, United Healthcare, and Cigna.
  • Cost-Sharing Collaboratives. Not really health insurance, but structured basically the same way and can provide some of the benefits of real insurance, so I’m including it in this section. These often feel like a cult, but I think the idea means well.
  • Healthcare.gov. This is almost always the best option for purchasing individual coverage on the open marketplace, so this is the one we’ll be focusing on for the rest of this article.

These methods of coverage represent 91% of Americans – the remaining 9% of the population is uninsured. The only benefit of not having health insurance is no premium payments every month, but you’re generally putting yourself at an undue risk if you fail to have any coverage at all. My hope is that most people reading this fall into this category and this article helps them obtain coverage. Don’t get overwhelmed! Take a break when you need to think about things. Follow the steps below to obtain health insurance through Healthcare.gov and you’ll be covered for next year. You can do it! Ask questions, if you need help!

What is Healthcare.gov?

Healthcare.gov (aka The Marketplace, The Health Exchange, Where You Get Obamacare) is the federal government’s health insurance enrollment portal. This is a marketplace where commercial insurers can sell “qualified” health insurance plans that meet the federal guidelines for minimal essential coverage set in the Affordable Care Act (ACA). While you can technically purchase the same exact coverage directly from an insurer, there are a couple things that make the marketplace unique.

  1. All plans on the marketplace provide minimal essential coverage and abide by the provisions of the Affordable Care Act. Commercial insurers can sell terrible plans that will never pay for a single thing you need on their own website, but all plans on Healthcare.gov are legitimate insurance plans that actually help pay for standard medical expenses. You won’t be denied due to pre-existing conditions, you’ll have coverage for (limited) preventive services, and you’ll have no maximum limit on benefits. You’ll have real health insurance that can help you, not just a paper card with an insurance company’s name on it.
  2. Plans purchased through Healthcare.gov can have your tax subsidy automatically applied to your monthly premiums. This is the best part, really. If you make less than 400% of the federal poverty level for your family size and qualify for federal assistance on your health expenses, you can apply to have your monthly premiums reduced by a prorated amount relative to your income. If you earn below the poverty level, you can possibly qualify for insurance with a $0 premium. This subsidy comes from your end-of-year tax credit towards health expenses and gives you that discount up front, so this doesn’t technically save you money on a long-term scale. I believe it is better to have access to your money every month, rather than waiting on a single refund at the end of the year.
    • Editor’s Note: For states that expanded Medicaid after the ACA, this subsidy is accessible by roughly 38% more people, and paid at a higher value. However, North Carolina is dumb and failed to expand Medicaid again, so we still have to pay part of the bill for those other states without getting any of the benefits. Yay!

Basically, you can get commercial insurance through any company, but getting insurance through Healthcare.gov is like buying a “certified” pre-owned car. You know it meets minimum standards for quality and will likely be each insurer’s best “value-to-benefit” option. If you can afford it and don’t qualify for subsidies, you may want to check out an insurer’s own website directly for premium plans and better coverage. Or, young and/or very healthy folks can also try to obtain worse coverage. For everyone else, the Healthcare.gov offers a great filter for quality, low-cost, effective health insurance plans.

Now that you have an idea what you’re looking for and understand the Marketplace a little better, it is time to look at actual coverage options. I wrote a breakdown of how to analyze two separate health insurance plans against each other a few years ago and everything still holds up well, so that is also worth reading if you are interested in the finer details of the plans.

Signing Up for Insurance on Healthcare.gov

I’m not going to write a step-by-step guide for Healthcare.gov, because the government already did! They spent a lot of money on the website, so it makes sense to use it. Click this link, or just type in healthcare.gov into your browser and go there directly.

For the 2021 Benefit Period, enrollment begins November 1, 2020 and ends December 15, 2020. You MUST register for insurance during this time period to have coverage effective on January 1, 2021. Outside of this window, you must qualify for special exemptions in order to sign up on Healthcare.gov.

The entire site stands as a great resource for uninsured individuals and thoroughly answers many common questions. About half the links I included above go directly to Healthcare.gov information pages, and I would simply be repeating a lot of their information. You can probably just go to the Healthcare.gov search page, type in your enrollment- or coverage-related question, and have the answer immediately.

Because the bulk of the detail has already been expensively explained on Healthcare.gov already, I’ve just included some quick reference items below. The site has a ton of information, so this should help you skip to very specific things that I think will cover 95% of your potential questions. If anyone asks a question about this article in the next 365 days, I’ll update the bottom of this post with the answers and make a note in the article above.

Good luck on your healthcare enrollment journey!

Notes & Links

ENROLL: To apply for or re-enroll in your Marketplace coverage, visit HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325

APPLYING: To help make the application process faster and easier, gather this information before you start your application. Here is an overview of what you’ll need, with more details and a fancy checklist through this link:

  • Demographic Information
  • Household Information
  • Addresses
  • Personal Details
  • Social Security Numbers
  • Information About Professional Helping You Apply
    • FYI – this is NOT me. I am not helping you apply. I am showing you how to apply and making you familiar with the plans you will be choosing from. I am not an insurance agent and am not choosing a plan for you. Nothing in this article will tell you to choose one plan over another. I just hope you will be comfortable with your choice after you’ve made it because you understand your plan, and the whole process, better.
  • Immigration Status
  • Previous Year’s Tax Filing Method
  • Employer Details
  • Household Income
  • Current Healthcare Coverage for Family Members, if any
  • Health Reimbursement Account (HRA) Notice

SUBSIDIES: Do you qualify for reduced premiums? This is what you need to do.

  • In North Carolina, you qualify for some level of subsidy if you earn less than…
  • The subsidy is prorated based on income. The size of your subsidy will be relative to your income level, on a scale between the federal poverty rate and your income maximum.
  • If you make below the federal poverty rate, you will likely qualify for free, or almost free, monthly premiums.
  • If you make more than the maximum income, your subsidy will be $0. Since the subsidies don’t matter, you should at least consider other options outside of Healthcare.gov. However, you’re still likely to find the best value coverage on the Marketplace and should thoroughly review the benefits of any plan that appears to be cheaper than your Healthcare.gov options.

QUICK LINKS: These pages are easily accessible on Healthcare.gov, but I’ve highlighted specific things you should focus on to help streamline the process.

Prior Authorizations

Prior Authorizations

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.

  1. 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.
  2. 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!

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 September 8, 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.