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.


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.


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.


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.


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.


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.


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!

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!

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.

North Carolina State Health Plan Options

To help all of the State employees of North Carolina figure out which version of the State Health Plan would be best for them during the upcoming year, I thought we would attempt to review the differences between the three options – CDHP (85/15), Enhanced 80/20, and Traditional 70/30. The State has developed a very informative site with lots of details and specifics for the State Health Plan, so I won’t repeat anything you can find there. The goal of this post is to compare, line by line, what the numbers associated with each plan mean and which types of medical situations end up being the preferred option financially for each person once all expenses have been considered.

All State Employees should have received a “Decision Guide for Open Enrollment” packet from their insurer for the 2017 benefit period sometime in the past few weeks. You can use the “2017 State Health Plan Comparison” table on Page 8 in this booklet, or you can click on this link to get the PDF online. Here we go!

2017 North Carolina State Health Plan Comparison

HRA Starting Balance: You’ll notice that the CDHP plan is the only option with an Health Reimbursement Account (HRA). An HRA is basically a fund that your employer sets aside to pay for your qualifying medical expenses. With the CDHP plan, an individual has their first $600 in health expenses paid through their employer’s HRA. This is basically free money, as long as you need it and use it for things that are approved by your plan (eg. doctor’s visits, most prescriptions). Effectively, this splits the CDHP’s $1,500 deductible into two different periods, where you end up only having to pay once you hit $601 in expenses each year.

One thing to consider is that you actually need to use $600 in health expenses for this aspect of the plan to help. If you don’t use it, the $600 set aside for you in your employer’s account usually resets and lets the employer keep any unused funds to help reduce expenses the following year. While $600 is the same to anyone, this is an especially nice feature for people who expect their total health expenses to be less than $600 per year because they’ll never have to pay anything except their premiums.

Annual Deductible:deductible is the amount of money you will have to pay out-of-pocket for non-preventive services before the actual benefits on your insurance plan will start to take effect. Of the three options available, the 70/30 has the lowest deductible, but that doesn’t mean it is the best plan. This means that the plan’s benefits kick in earlier, but the 70/30 plan also has greater expenses after the deductible and a much higher out-of-pocket maximum than the other plans. Other than just the dollar amount, there are two distinct differences in how these deductibles are applied:

  • The CDHP plan applies all medical expenses to the deductible. Your sick visits, specialist appointments, prescriptions – everything goes towards your initial $1,500 deductible. Other than the covered ACA Preventive Services, this plan doesn’t pay any of your health care expenses until after you have met the deductible.
  • The 80/20 and 70/30 plan have co-payments for PCP visits, urgent cares, and prescriptions so the deductible only applies to things like surgeries, labs, and hospital visits. While the deductibles are lower, they are also less likely to be met because they only apply to certain things.

Co-Insurance: You might notice that the co-insurance rate is also indicative of the name of the plan – eg. the 80/20 plan features a 20% co-insurance. The co-insurance is a percentage that requires the patient to pay a certain portion of approved medical services once their deductibles have been met. Basically, as a reward for paying 100% of everything out-of-pocket before you met the deductible, your insurance will now start helping pay your health expenses by reducing your portion to either 15%, 20%, or 30%, depending on the plan. Once you have met your deductible, this is the percentage of your health expenses you will be required to pay until you have met your co-insurance maximum.

Medical Co-Insurance Maximum: The 70/30 plan is the only one that has a medical co-insurance maximum. The other plans have their own maximums, so while this seems like a small bit of semantics, but it actually makes a pretty big difference in your possible expenses. The CDHP only has a combined out-of-pocket maximum that includes co-insurance and pharmacy benefits, while the 80/20 plan skips the co-insurance maximum and separates the out-of-pocket maximums between medical and pharmacy. By calling it a “co-insurance maximum” and not a “out-of-pocket maximum,” this number does not include the annual deductible that has already been paid.

This graphic does not include the separate prescription deductibles associated with the 80/20 and 70/30 plans.

Because the $4,350 out-of-pocket maximum in the 80/20 plan includes the $1,250 deductible, the 80/20 plan’s effective “co-insurance maximum” is really only $3,100. With the 70/30 plan, you’ll be paying the $1,080 deductible PLUS $4,388 more. A small difference, but one that costs over $1,200 if it actually comes into play. Also, it is important to remember that the 80/20 and 70/30 plans have separate deductibles for prescriptions, which we will get into soon.

Medical Out-of Pocket Maximum: As mentioned in the previous paragraph, the medical out-of-pocket maximum includes all out-of-pocket expenses a person would have to pay for medical services each year. This includes co-payments, co-insurances, and deductibles. For the 80/20 plan, this means you’ll have a cap on your medical expenses each year of $4,350. Because this number includes the deductible, you’ll basically be paying a $1,250 deductible, and then +20% of the next $15,500 in health expenses you incur (for a total of $4,350). This number puts a cap on your total annual medical expenses, so you can consider this the limit of a “worst case” scenario (not including prescription coverage).

Pharmacy Out-of Pocket Maximum: This is just like the medical out-of-pocket maximum described above, but only for prescriptions. The 80/20 plan and 70/30 plan both have separate deductibles for prescriptions, while the CDHP plan assigns both medical and pharmacy claims towards the same deductible. This makes it seem like the CDHP plan has better prescription coverage than the 80/20 or 70/30 plan, but those two only apply their deductibles to high tiered prescriptions that aren’t used by very many people. With the 80/20 and 70/30 plans, most of your prescriptions will be a set price for a 30- or 90-day supply, so most people will never really get close to meeting their limits with simple $5 and $30 co-payments per month.

Out-of-Pocket Maximum (Combined Medical and Pharmacy): The basic concept was covered in the previous two sections, but this number represents the “worst case scenario” for all of your out-of-pocket health expenses combined. There is no scenario where an individual will have to pay more than $3,500 on the CDHP plan, $6,850 on the 80/20 plan, or $8,828 on the 70/30 plan. This is a helpful number to know if you’re going to need a major surgery or hospitalization. These numbers are relatively low compared to today’s health insurance environment, where standard maximums are usually around $10,000 or $15,000 annually, so this is a one of the best aspects of the State Health Plan and a major selling point for most people.

ACA Preventive Services: These are the rates for certain services that have been categorized as “preventive” by stipulations in the Affordable Care Act, which has been adopted by the State Health Plan. You can check out the details of what is considered a preventive service on the State’s website – this includes things like your annual wellness exam, most vaccinations, and standard age-based guidelines and screenings. Preventive medicine has been proven to keep people healthier, so insurer’s are making a big push to ensure all of their members get these basic, cost-effective primary care services now so they can avoid having to pay for complicated, expensive hospital visits later. Because the services are preventive, and not urgent, the insurance penalizes you significantly for receiving these services out-of-network, so make sure the provider you see accepts your insurance if you want to receive these benefits.

Office Visits: So far, everything has basically seemed most favorable to the CDHP 85/15 plan. The next few topics are where the real benefits of the 80/20 and 70/30 plans come in, since they have co-payments for most medical services, instead of a deductible. While their deductible may be higher, it also applies to fewer things that you are likely to need. This is also the part of your benefits that applies to appointments at Family Care, if you were wondering.

For example, consider a single primary care visit for the flu – to make it easy, we’ll say its your first visit of the year.

  • With the CDHP plan, you are paying 100% of the cost of the visit because you haven’t met your deductible yet. This includes the doctor’s visit, flu testing, lab work, prescriptions, and any other services you may need. However, if the visit falls within the first $600 of your annual health expenses, the charges would be paid by your HRA account and you would not owe anything out-of-pocket. You would also get $25 added to your HRA, so you can think of that like a cash-back rebate towards your health expenses for using an in-network provider. After your HRA has been exhausted for the year, you will owe 100% of every office visit you have for the next $900, and 15% after that until you reach your maximum.
  • With the 80/20 plan, you would only pay a $25 co-payment for a doctor’s office visit, rather than having the charges applied to your deductible and owing 100%. Basically, you would save about $75 every time you went to a PCP and $215 every time you went to a specialist. If you had any testing or additional services (eg. flu test, breathing treatment, etc.), your deductible would apply in addition to your co-payment. This makes things relatively simple and helps people budget costs once they expect to have several office visits each year.
  • The 70/30 plan has the highest co-payments, but they are still not too far off from the 80/20 plan and the deductible applies to PCP visits the same way. You will have a higher co-payment, but still pay the same rates for additional services towards your deductible.

Urgent Care: Just like the section on Office Visits, but in an Urgent Care setting. There isn’t too much different about the basic process from office visits, so the main thing to notice is how much higher your expenses will be at an urgent care vs. your primary care provider. Whenever possible, you should always try to visit your primary care provider before attempting to go to an urgent care. For example, at this great independent primary care facility known as Family Care, we can guarantee either same-day or next-day appointments, so we can help you avoid the higher costs and lower quality of service that you’re bound to experience at an urgent care facility.

The nice thing is that the benefits for urgent care visits are identical at both in-network and out-of-network providers. Because the problem you are experiencing is obviously “urgent” if you are visiting an urgent care, your insurance company won’t care about the network and allow you to get treated wherever is most convenient. They charge a steep fee for this convenience, but it is still nice to know you won’t be charged more because of the network.

Emergency Room: Again, the CDHP plan applies charges to a deductible, while the 80/20 and 70/30 plan have co-payments associated with the visits. Depending on the significance of your reason for visiting the ER and how close you are to meeting your deductible, either one might be considered the best option for your situation. The one, and probably only, benefit to an ER visit is that you’ll likely go well beyond your entire out-of-pocket in just a few hours, so your healthcare will basically be “free” for the rest of the year. Yay for you!

Inpatient Hospital: This is reserved for actual hospital stays where the patient is admitted and kept in the hospital for some period of time. With all of the plans, you’ll only end up receiving the benefits in this row if you visit the ER and are then later admitted to the hospital. The insurance does not try to charge you twice after an admission, so the bump from an ER visit to an admission is not too drastic. The CDHP and 80/20 plans have an option to either get money back or have their co-payments waived if you visit a Blue Options Designated Hospital, so you should try to visit a preferred hospital whenever possible.

Prescription Coverage: The concept of tiers is pretty complicated, so I will go over this part in a separate post. However, the basics are still pretty much as the regular medical benefits the same across the three options. The CDHP has prescriptions applied to the same deductible as everything else, while the 80/20 and 70/30 plans have co-payments associated with different tiers of drugs. If you aren’t sure what these terms really mean, here is a good 2.5 minute video on what a drug formulary is and why your insurance has grouped different drugs into tiers.

For the State Health Plan, specifically, here are the links to the specific formulary for each plan. You should look up the medications you take to determine what tier they are classified under so you can get a good idea of your expected costs for that drug. The formulary changes all the time and the difference between a Tier 1 drug and a Tier 2 drug could be hundreds of dollars per year, so this helps keep you from being surprised when you show up at the pharmacy.

Which plan should I choose?

In my opinion, the State Health Plan is the best health insurance to have in North Carolina. Each plan has their specific benefits and drawbacks, but they are all significantly better insurance plans than the plans you’re likely to find available on The problem is finding the plan that makes the most sense for how it will actually be used by you and your family. Every medical situation is unique, but here are some of the pros and cons of each plan to might help you make your final decision.

CDHP (85/15)

  • Pros: Potential for $0 premium and includes the lowest cost to add children and/or spouse. If you spend under $600 per person, your out-of-pocket expenses will be paid entirely by your HRA. This plan has the lowest out-of-pocket maximum, so this plan has the best “worst case scenario.”
  • Cons: You are required to pay for 100% of your expenses between $600 and $1,500 each year. You’ll have to pay for prescriptions under the same deductible as medical expenses. You’ll need to take additional steps to set up your HRA with your employer.

Enhanced 80/20

  • Pros: Lowest co-payments for PCP and Urgent Care visits, as well as most prescriptions. Pharmacy deductible is only $2,500, so meeting that deductible could help reduce overall costs if prescriptions make up a large percentage of your medical expenses.
  • Cons: Requires at least $15 per month, minimum, in premiums and has the highest premium cost to add family members. Potentially has the highest cost in a situation where multiple family members need extensive care and prescription coverage.

Traditional 70/30

  • Pros: Has a lower premium than the 80/20, but still maintains a similar structure for PCP and urgent care visits. Has co-payments for Tier 3 medications, so certain medications might be cheaper than the other plans. One prescription deductible applies to the entire family.
  • Cons: Has the worst coverage after the deductible has been met of the three plans. Because the premium is similar to the CDHP, while the coverage is similar to the 80/20 plan, the segment of people that would have the best coverage for their unique situations is fairly narrow. Most people would be better off getting the CDHP or 80/20, but there is a definite middle group where this plan makes the most sense.

I hope this was a helpful breakdown of the major components of these three plans. For more details on how you should think about this information, in general, be sure to check out our recent post on the 3 things you should consider when signing up for health insurance.

If you have any questions, please submit them in the comments and I’ll be sure to reply. Thanks for reading!

Prolia Medication Guide

This page is a handy resource for patients at Family Care who have started taking Prolia. Please use the links below to access patient education materials that are required to be given to our patients before beginning treatment on Prolia. If you have any questions, please call our office and ask to speak with our nurse. Thank you!

Prolia Patient Brochure

Prolia Medication Guide

Prolia® is a prescription medicine used to:

  • Treat osteoporosis (thinning and weakening of bone) in women after menopause (“change of life”) who:
    • are at high risk for fracture (broken bone)
    • cannot use another osteoporosis medicine or other osteoporosis medicines did not work well
  • Increase bone mass in men with osteoporosis who are at high risk for fracture
  • Treat bone loss in men who are at high risk for fracture receiving certain treatments for prostate cancer that has not spread to other parts of the body
  • Treat bone loss in women who are at high risk for fracture receiving certain treatments for breast cancer that has not spread to other parts of the body

Acne Prevention

Almost everyone at some point in their lives will suffer from acne outbreaks. While it can be embarrassing or frustrating, there are many easy ways acne prevention can help reduce the occurrence of breakouts. We tend to think that only teenagers should be plagued with pimples, but unfortunately, acne can be present our whole lives.

Ways to help reduce acne outbreaks:

  • I would encourage a well-balanced diet and plenty of water to keep the skin nice and hydrated. Although some people will find they break out after eating certain foods, there is no evidence that fatty or greasy or sugary foods lead to more breakouts.
  • Make sure to wash your face with hands and not a washcloth as these may be abrasive to sensitive skin. Some acne washes contain Benzoyl Peroxide or Salicyclic acid, both of which can be very harsh to the skin. They may lead to peeling and redness, along with increased sensitivity to the sun.
  • If you try an OTC acne cream, be sure to test it on one spot first before applying to you whole face to minimize adverse reactions.
  • Keep your hands off your face to reduce spreading grease and other irritants onto your face. Temptation to squeeze pimples can be hard to resist, but it can actually lead to tissue damage, infection, and scarring. Try not to pick!
  • Makeup can irritate and clog pores as well. Make sure to always wash off your makeup at the end of the day. Products that are water-based or more natural tend to be easier on the skin, as well.

Products I love and have found to be effective in helping clear my own skin include:

  • Cetaphil face wash. This is an incredible, gentle skin cleanser. It is available at almost all drug and grocery stores and is relatively inexpensive.
  • Cetaphil moisturizer. Again, this brand is really gentle on the skin. There is a moisturizer with, and without, sunscreen. It goes on smooth and does not feel like you are wearing a thick layer of moisturizer. Sunscreen is always a good idea to help prevent skin damage.
  • Neutrogena products. There are many Neutrogena products, but the ones I think are the best include the Oil Free Acne Wash for the face and Clear Body Wash, for back and chest acne. These products tend to be less drying to the skin than some of the other available washes.
  • Neutrogena moisturizer. There are several moisturizers with sunscreen in them that go on smooth and do not leave an oily residue. There are also overnight moisturizers to help fight off any dry skin.

Finally, if the OTC and home remedies are not working, you should come see us to discuss topical therapies or other medications to help reduce acne flares!

Sarada Schossow, PA-C is a primary care provider at Family Care, PA in Durham, NC. She has special interests in women’s health, adolescent and young adult health, and dermatology, including acne prevention. For more articles from Sarada, click here.

What is a “grandfathered” health insurance plan?

What is a “grandfathered” health insurance plan? 

A grandfathered health insurance plan means that the plan does not have to follow the national healthcare reform guidelines implemented by our federal government as part of the Patient Protection and Affordable Care Act (ACA) in March 2010.

There are two types of grandfathered health insurance plans:

  • Job-based grandfathered plans. Job-based grandfathered plans can still maintain their grandfathered status if the plans haven’t been changed in ways that substantially cut benefits or increase costs for plan holders and notify plan holders that they have a grandfathered plan. To keep a job-based grandfathered plan, the employer must have continuously covered at least one person in the company since March 23, 2010.
  • Individual grandfathered plans. Individual grandfathered plans can’t newly enroll people after March 23, 2010, and have that new enrollment be considered a grandfathered policy. But insurance companies can continue to offer the grandfathered plans to people who were enrolled before that date. An insurance company can also decide to stop offering a grandfathered plan. If it does, it must provide notice 90 days before the plan ends and offer enrollees other available coverage options.

While the majority of stipulations in the ACA apply to all types of health insurance plans, grandfathered plans are allowed to maintain a lower standard of coverage as a political compromise towards meaningful reform. With their grandfathered status, these plans have a different set of requirements:

It is important to understand the reasoning behind the changes made with the ACA and why our government had to do something to fix a broken system before it was too late. Before the ACA took effect, health insurers had a completely disproportionate advantage on the patient/insurer relationship. These healthcare reforms have been long overdue and were actually set up to help patients regain control from health insurers, no matter what other motives you might hear on Fox News. It is named the “Patient Protection” act, after all. You may remember some of the many ways health insurers ripped people off before the ACA:

Do any of these ideas sound fair to you? Obviously not. I think we can all agree that putting a stop to these devious insurance practices is a good thing for the healthcare industry, overall.

Despite the obvious benefits of having an ACA compliant plan, it does make sense for some people to continue coverage under a grandfathered plan. However, 3 out of 4 people with employer-based health insurance have an ACA compliant plan, along with almost everyone who is insured through the individual marketplace, so having a grandfathered insurance plan means you are going to face challenges and issues that do not apply to most of the population anymore, thanks to the ACA. Here are a few closing points to consider:

  • The majority of the advertisements, articles, new stories, and policy discussions that you see in the media regarding healthcare do not apply to you.
  • Your out-of-pocket costs will most likely be significantly higher than someone with an ACA-compliant plan.
  • Your “preventive wellness exam” is not covered by your insurance. If you have a copay or deductible, those will still apply to this visit.
  • You do not have the right to appeal any decision by your insurer. This includes denials for prescriptions, imaging, and medical claims.

Patients Asked Thrice: Healthcare Insurance and Billing Q&A

This post is part of a series entitled “Patients Asked Thrice,” which is designed to answer questions I have received at least three times from our patients. The inspiration comes from the saying: “One’s an incident, two’s a coincidence, and three’s a pattern.” If three different people ask me the same thing, I can safely assume there is at least a fourth person out there who wants to know the answer.

If you have any other questions you would like me to address, or any follow up questions to this post, please include them in the comments section below. Thank you!

Diabetes In The United States

Because November is National Diabetes Awareness Month, we are focusing on topics relevant to diabetes and how we can help our patients with the diagnosis.

Instead of a bunch of words, simply posting this nice infographic from the CDC seems like a much more efficient way for me to tell you that diabetes is widespread concern that probably impacts someone you know. Please take a moment to at least skim some of the statistics and details about diabetes in the graphic below. On a side note, I may or may not have chosen this particular infographic because it fits in so nicely with our website’s color scheme.

If your diabetes is uncontrolled or believe you are at risk of developing diabetes, please contact your physician and schedule an appointment. If you are interested in learning more about how you can help yourself or someone you love, the American Diabetes Association offers a free program to people with type 2 diabetes called “Living With Type 2 Diabetes.”

The program, available in English and Spanish, provides information and offers free guidance to help people learn how to manage diabetes at regular intervals throughout the year-long. People can enroll into this free program by visiting, calling 1-800-DIABETES, or texting Type2 to 69866 to learn more about the program in English or Tipo2 to 69866 to learn more about the program in Spanish.

Topics and resources include:

  • Food, nutrition and recipes
  • Stress and emotions (see infographic below)
  • Physical activity
  • Complications
  • Peer support online and via phone
  • Support from the Association’s local office
  • Support from the Association’s National Call Center
  • Opt in text messaging

– See more at:

What is a Physician Assistant?

What is a Physician’s Assistant?

Since we have added a wonderful Physician Assistant, Sarada Schossow, PA-C, to the practice, I thought it would be beneficial to our patients to outline what exactly a Physician Assistant is and how they are used in family practice. Here is the official definition of a Physician Assistant, according to the American Academy of Physician Assistants:

“Physician Assistants (PAs) are health care professionals who practice medicine with physician supervision. They conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and write prescriptions. They are often found in primary care practice — family medicine, internal medicine, pediatrics, and obstetrics and gynecology — but also work in many specialties, such as cardiology, emergency medicine, oncology, dermatology, gastroenterology, psychiatry, and in surgery and the surgical subspecialties.”

To better relate the concepts to patients, “A Patients Guide To Physician Assistants” created the “Patient’s Definition” of a Physician Assistant. This helps patients understand how care with a Physician Assistant will be seen from their perspective and has three basic categories that a Physician Assistant might fall under:

Physician representativesBasically, a Physician Assistant is like a vice president that acts on behalf of their president (physician). PAs are competent and qualified healthcare providers that serve as representatives for their physician in doing most of the things for you that the doctor would. They are more of an associate than an assistant that helps to improve the efficacy of the physician’s practice. This means that if the doctor’s office that you visit has several Physician Assistants then you should see an overall decrease in wait time and an increase in time with the healthcare provider (PA or physician). It also means that you should be able to get appointments sooner because there are more healthcare providers to choose from.

Generalists. An important aspect to understand is that physician assistants are generalists. They are trained extensively in the same medical model that is used for doctors. Being a generalist allows them to have a wealth of knowledge in many areas of medicine. This means that they are able to approach your medical concerns from a whole-body perspective.

Patient Educators. One of the primary roles of the Physician Assistant is patient education. A patient that understands their illness and what they need to do to fix it will hopefully be able to prevent further illness. In other words, understanding is a key to wellness and prevention. PAs often have more time with the patient in order to educate them about their health.

At Family Care, Sarada Schossow, PA-C will be working directly with Dr. Sabrina Mentock and Dr. Elaina Lee to provide great continuity of care for our patients. Sarada Schossow, PA-C will allow Family Care to maintain the same personal level of care we currently show to each of our patients, while still having the ability to meet the growing demand for high quality medical care in our community.

To accommodate our growing volume of patients, current patients may be offered the chance to see Sarada Schossow, PA-C for certain types of appointments at times that may be more convenient or immediate than their current provider can arrange. These types of visits include:

  • New patient appointments
  • Acute illnesses and conditions
  • Annual preventive wellness exams
  • 5pm-8pm visit requests on Monday and Tuesday

Because this is a rather new concept for patients at our practice, here is another quote from “A Patient’s Guide to Physician Assistants” regarding the types of services a Physician Assistant can provide:

When making a decision about whether to see a NP, PA, or MD most of the time it should not matter. The reason is that the NPs and PAs are also trained to know when something is beyond their ability or understanding. They should know when to refer you to a specialist or a physician. Any of the above practitioners know how to research and consult other practitioners in order to bring you the care you require. Doctors have more formal education and training to draw from, but aside from that there is much more variance in personality and individual dedication to the patient then in the type of provider you chose.

Check our Sarada’s introduction video below!

We are very excited to add Sarada Schossow, PA-C to our team and think she is a great fit with our practice. If you have any questions about the role she will play in providing great care for our patients, or would like to schedule an appointment, please contact our office!