#Demystifying Health Insurance Terms: A Guide for Patients
"Co-pay", "Deductible", "Max out of pocket costs", "in-network", "out of network", "premiums".
With benefits open enrollment season upon us, have you ever looked through some of these plans and terms above and found yourself scratching your head? Or maybe just yelling "WTF" to the universe? Do you find yourself overwhelmed or frustrated with the increasing costs of healthcare? Not only the insurance premiums, but the lack of what is covered when you DO need to see a provider? The out of pocket costs, the lab work up, the prescription costs, imaging costs, etc. The list goes on and on and the dollar signs go higher and higher. What I have found over the years and still see to this day, is the substantial amount of people confused on what each of these terms mean and what their individual plan covers or doesn’t cover. Not only that, we as clinicians receive a lot of the frustrations when things are not covered, or the cost is substantially high. "Why would you order this medication if you knew it was x amount of money?" "Why would you order this lab and not code it to be covered?" "Why does my insurance NOT cover this medication, when it's listed under the formulary as "covered"? Let me tell you, WE AS PROVIDERS are JUST AS FRUSTRATED as you all are. They don't teach you in medical school or PA school all the red tape and regulations that go into healthcare. They don't teach you what "codes" to use to get items covered and they certainly do not teach you even while being a clinician the COST of each office visit, medication, etc. Did you know that in a traditional model, we code each diagnosis based on what is called "ICD-10 Codes", and there are over 70,000 codes to pick from (no, I'm really serious!). We also have to submit each visit for coding, and pick from CPT codes: which also have over 11,000 codes to pick from. Yes, we do have some of the most “common” codes used in Primary Care, however each code is then associated with a contracted price. And EACH insurance and EACH plan under that insurance has different “contracted” prices…meaning how we are paid. In addition, there are approximately 900 health insurance companies in the US, all of which might have an additional 3-5 "plans" to pick from, all of which have different levels of deductibles, different levels of coverage and different regulations, as well as different “formularies” for prescription costs. Seems complicated right? Well, that’s just the beginning.Navigating the world of health insurance can often feel like trying to speak a different language in a country you’ve never been to. These terms can leave many patients AND providers confused and frustrated. Now is the perfect time to break down each term and promote a TRANSFORMATIVE approach to healthcare, one that SIMPLIFIES healthcare: this is called Direct Primary Care. And while I am certainly NOT an insurance agent, nor claim to be one, over the past year, I have become even more familiar with the terminology associated with insurance. So, let’s break it down for you.#Understanding Key Health Insurance Terms:
1. What is an insurance premium?
-This is the actual cost of your insurance plan that you, or an employer may contribute to/pay every month. These can be paid monthly, quarterly or yearly, and the premium does NOT contribute to the deductible or out of pocket costs. If there is a missed payment, this can lead to a lapse in coverage, so it’s absolutely crucial to budget for this cost. 2. What is a deductible?
-This is the amount of money you are required to pay for healthcare services OUT-OF-POCKET BEFORE your insurance starts to kick in and cover a portion of the costs. For example, if you're deductible is 2,000 dollars, your plan won't pay for care until you spend this amount on covered services. Also, "pay for care" often means something different on every plan, with the majority meaning it’ll pay for 80% of covered costs (some less, some more), until you hit your MAX-OUT-OF-POCKET costs. Leading us into…3. What is "max out of pocket"?
-Now, you've just spent 2,000 dollars and reached your deductible! YAY! You show up to a visit, or the pharmacy thinking "now my insurance will cover this." and you get yet another bill in the mail, maybe a month or 2 later. Well, here we go friends. This is the "max out of pocket" scenario. Despite the deductible being met, most insurance plans also have a "max out of pocket" cost. This is the maximum amount you will ever pay for covered services in a policy year. Once you reach THIS limit, then your health insurance will cover 100% of expenses. This may sound beneficial…however most individuals will never meet this max out of pocket cost and thus end up paying a large amount of money before any of these items kick in. For example, if we take the same scenario listed above with a deductible of 2,000 dollars, you may have a further max out-of-pocket cost of 8,000 dollars. The majority of office visit CONTRACTED rate costs for primary care are between: 280-350 dollars PER visit. This does not include specialists, lab work, medications, sick visits, point of care testing (strep, covid, influenza swabs) or procedure costs. You could have 2 office visits and 1 urgent care visit for the year, and you’ve already reached the cost of our direct primary care membership for the ENTIRE year. 4. What is a co-pay then?
-A co-pay is a fixed amount of money that you pay for a specific service or medication at the time you receive it. For example, you may pay $25 when visiting a doctor but have a different co-pay for prescriptions or specialist visits. This can be a point of confusion as co-pays can vary WIDELY among different plans and services. Most of the time, co-pay costs are right on your insurance card. 5. But wait, what about preventative care?
-This is any service considered by your insurance company as services intended to keep you healthy, help prevent diseases or prevent chronic health conditions. This may be annual check ups, counseling advice, screening labs and vaccinations. However, while there are certain preventative care items we KNOW are covered (Cervical cancer screening, Mammograms, Colonoscopy, etc), we do NOT know exactly what items are considered “preventative” in lab work screenings, which often causes more confusion and frustration when patients are told things will be covered, but in turn, get a bill for their items. In addition, I have been doing obesity medicine for the past 4 years and while I know if we don’t treat obesity, this can lead to a long list of chronic diseases (preventing them from happening), this PREVENTATIVE treatment is typically not covered. We have had improvements over the past few years, but we are nowhere where we need to be on this. 6. LAST but certainly NOT least: In-network vs. Out of network:
The above situations were describing in-network deductibles and in-network out of pocket max considerations. In-network providers have agreements DIRECTLY with your insurance company to provide services at “contracted” or reduced rates, which means you in turn pay less when you see them. Out-of-network providers do not have these agreements, resulting in higher costs, or in some cases, no coverage at all. Most insurance plans also will have listed out-of-network deductibles and out-of-network max out of pocket costs on your card, and the average max out of pocket for an out of network provider is close to 15,000 dollars. Navigating these networks is hard, and at the end of the day, when you are paying a premium monthly for coverage….shouldn’t you be able to CHOOSE who YOU WANT TO SEE? Out of network costs make that nearly impossible for anyone to afford that care. #The Confusion and the Stress
For many individuals, deciphering these terms add an unnecessary layer of stress to healthcare. Misunderstanding insurance language can lead to unexpected costs, delayed care, or even avoiding necessary medical attention due to financial worries and the unknown. Adding to the complexity, insurance plans (as you’ve seen) can vary widely not just by provider, but also by individual policies, making it cruicial to read the fine print. Unfortunately, health literacy rates vary and many consumers feel overwhelmed by all this lingo. #The Solution: Direct Primary Care
As open enrollment approaches, considering transformative and alternative ways to the traditional insurance based model is vital. One such alternative is Direct Primary Care, often referred to as “DPC”. DPC provides patients with a straightforward monthly subscription model for primary care where high quality care, unlimited visits, direct access to your healthcare team, individualized care and access to HIGHLY reduced cash-based lab fees all fall under your monthly membership. Not only that, but the costs of procedures are HIGHLY reduced as well. While DPC is certainly NOT a replacement for Health Insurance, the reality is that most Americans have shifted to a high deductible insurance plan. With enrollment season starting, now is the time to check those premiums, and fine print. Shifting the cost to a high deductible plan, catastrophic plan and pairing it with a DPC membership, can actually save you HUNDREDS of dollars. Why? Well simply because of the benefits of Direct Primary Care. #Benefits of Direct Primary Care
SIMPLICITY
-DPC Eliminates the RED TAPE holding you back from having a DIRECT relationship with your provider. Remember all those terms above, well DPC eliminates the confusion of the multiple terms and hidden fees. For the flat-rate monthly fee, patients have access to their primary care doctor, without the hassle of insurance claims, or co-pays. We’ve been asked many times “What’s the catch?” and we keep saying, “nothing”. We MEAN it. There is no additional co-pay you pay when you want to be seen. You DO get to talk DIRECTLY to us, not a phone bank or waiting hours to hear back. It allows us to actually put YOU, the patient, FIRST.PERSONALIZED MEDICINE
-Did you know, because of insurance regulations and “contracted” pricing, that the “contracted reimbursement” to primary care providers has continued to drop every single year. You don’t have to be a business owner to know the dynamics of: if you get reimbursed less, the only way to make that up is what? You guessed it…BOOKING IN MORE APPOINTMENTS. In addition, the average “time” you get to spend with your primary care provider in a traditional insurance based model, is down to 11 minutes. If this continues, that time will only drop, leaving you feeling unheard, rushed and also burning out primary care clinicians and leaving the specialty (or worse, medicine) all together. In a traditional setting, Primary Care providers often take on: 2,000 patients or more on their panel (no joke!)-So, how does DPC fix this? By eliminating insurance contracting all together, DPC allows for longer appointment times and more personalized care. We do this, because we have limited our patient panel size to 400-500 patients, ensuring you get all the time you need for your health. When you feel heard, get individualized care and DIRECT access to your provider, this fosters a better relationship between you and your clinician.ACCESSIBLE CARE
-We believe that QUALITY healthcare should be accessible to everyone and really do prioritize VALUE over VOLUME. The average wait time to get in with your primary care provider in a traditional setting is 29 days (this is if you have a primary care provider), if you don’t, this wait time can be upwards of 3+ months and most recently I have heard some individuals say >1 year. In DPC, when we take on less patients, we are ABLE to offer next-day, sometimes even same-day appointments. Not only that, we operate with a DIRECT line to your primary care provider, REALLY! You get our personal line, that is private and not given out to the public. This direct access can alleviate anxiety for patients who need that timely care, or even offer some reassurance when you have a quick question.TRANSPARENCY
-Not only is our pricing in DPC very straightforward, patients know what they are paying and what services are covered under that cost. It removes the stress of unexpected bills that arrive in your mailbox months later. In addition to our pricing, we also feel it is SO important for YOU to know AHEAD of time when our office is open or closed. Whether that is for Holidays, weather related events, or your provider is out on vacation, we have this readily available to you on our MEMBERS ONLY page.AFFORDABILITY
-With our affordable monthly fee, most individuals find they can actually save money long-term by combining a DPC membership with a higher deductible insurance policy or cost sharing plan. Eliminate the fear of being seen due to cost and enjoy the comfort knowing you can keep you and YOUR family healthy.
YES:
Most of our patients carry insurance for items OUTSIDE our office. Some have high deductibles and some do not. Why? Because it comes down to what you want out of your healthcare needs and who you want by your side navigating this ever changing healthcare field. YES:
We will see you if you have insurance or don’t have insurance. Remember, we do not contract with any insurance companies, which means this opens the door for YOU to CHOOSE who you want to see, no more worrying about in-network or out of network terms. YES:
Family Medicine providers see patients of ALL ages. This means in our office, we can see infants, children, teens, adults, grandparents. We also provide obstetric care up to 36 weeks and transfer you to a delivering physician.YES:
We can still use your insurance for things OUTSIDE our office: Specialists, imaging, screenings, medications, etc. If you have an in-network facility, we can send all of these orders to the facility you need.YES:
We do offer vaccinations in the clinic and YES these are ran through your insurance. How? We’ve partnered with a pharmacy in town, that bills your insurance for these vaccinations. YES:
We really are telling you the truth…there is no catch. YES:
We really do believe that Direct Primary Care is the answer to transforming primary care, and we can’t imagine taking care of our patients in ANY other way.STOP WAITING
Review your health plan, talk with your benefits director and take charge of your health by exploring this TRANSFORMATIVE way of care. Join Resurgent Health today or schedule a free meet and greet with us to hear how passionate we are and how we can truly improve your healthcare journey today. *Resurgent Health acknowledges that we are NOT a replacement for health insurance and we do still recommend that you sign up for some form of insurance after discussing with your benefits director. We also acknowledge we are not an insurance company and can not legally advise you on the type of plan to get.
