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Understanding Your Insurance Benefits

by Khrstyn Hill

This is an all too common story. You fall, hurt your back and your doctor tells you that you need physical therapy. Without checking with your insurance you attend 10 physical therapy visits and you feel fabulous. Your doctor said you needed it so it must be covered completely, right? Then you receive a bill in the mail two weeks later for $600. How could this be? You think to yourself, I pay my insurance premium monthly there is no way I should get a bill! Just knowing and understanding you benefits can eliminate this shock and help you plan your finances.

 
By Robbie Grubbs from Houston (What????) [CC-BY-SA-2.0], via Wikimedia Commons


Plan Ahead

First things first, CALL your insurance company before receiving any type of medical services. On the back of your insurance card there is always a Members Services phone number listed. Use this number frequently! This will help you determine what your coverage is for every procedure, test, or visit you may need. Many people believe anything their doctor may order is covered completely. This is not the case. Rarely is anything covered at 100%. This is why it is so vital that you call your insurance company before receiving services. We have an insurance verification worksheet to use as a guide when checking your insurance benefits.


United States Library of Congress's Prints and Photographs division under the digital ID cph.3b17965

Understand your benefits

Next, you must understand your benefits and how they work. It’s great to know what your benefits are, but not understanding them will leave you in the same state of shock as not knowing them in the first place. Services you receive may apply to a deductible and coinsurance or straight copay. A deductible for health insurance is much like the deductible on your auto or home insurance. This is the set amount that you must pay out of pocket once a year before you insurance will cover even a penny. This amount can range from $50 to upwards of $10,000. As you can imagine knowing this amount is extremely important.
 

Deductibles

Before your deductible is met for the year, you are responsible for the covered health care services before your insurance plan begins to pay. Most deductibles can range from $250 - $5000 depending on the insurance plan. Once you have met your deductible, only then will your insurance start to cover a percentage of the bill. This can range from 50% up to 100% of the contracted insurance rate. This means you may still be responsible for up to 50% of your charges AFTER you have met your deductible. When a service applies to a copay, it means that you are required to pay a set amount every time you receive this service. Copays may range from $5 to upwards of $60.

Copay and Co-insurance

So what’s the difference between a copay and co-insurance? Great question, I thought you would never ask. Where a copay is similar to a service fee (due at your appointment), a co-insurance is a percentage of the overall bill that your insurance company requires you to pay. Co-insurance can range anywhere from 5% up to 50%. Once you have met your deductible, then your insurance picks up a percentage of the bill and leaves the rest for you. So, let’s say you have a 20% co-insurance and have met your deductible. The cost of the service was $150. Your insurance is going to pay $120, or 80%, and $30 is your responsibility.
 

Payment options

Once you receive a bill in the mail there are many payment options. Pinnacle Medical Wellness offers online payment, pay by mail or phone (425-433-0123, option 1), and payment plans. If you have a Health Savings Account (HSA) or Flexible Spending Account (FSA) you may also take advantage of those benefits and pay with your plan's card or get reimbursed.

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Plan ahead

Now you know what your benefits are, and you understand what portion of the bill will be your responsibility, so what next? Plan, plan, plan. You cannot get around medical expenses but you can get on top of them. Take control of your expenses and have a plan in place so that you can get the care that you need. Take advantage if the expertise your provider has developed in dealing with insurance companies. Ask questions and be proactive in understanding your benefits.

Related sections:

Patient Resources

Services

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