In many cases, your child's care and treatment is dictated by the insurance companies. If you understand the language of insurance, you'll be able to more effectively manage the cost of your child's care and medical bills. Insurance companies frequently make mistakes on claims. Carefully read every Explanation of Benefits (EOB) you receive. And keep track of your out-of-pocket payments so you don't pay more than you should.
Basics of HMOs
HMOs, or health maintenance organizations provide patients with a network of physicians and facilities that they can use for their medical needs. The physicians and practices in this network accept a predetermined fee for their services. This helps keep the overall costs of the HMO down, while providing business for the providers.
Participants in an HMO must choose a primary care physician (PCP) who oversees most of their medical care. If you need to see a specialist or get lab work, your PCP will help you choose one in your network. In most cases, the PCP will need to provide you with a pre-authorization form or referral for the appointment.
Most patients who have an HMO pay a monthly fee and an additional co-payment for each doctor visit. These fees vary depending on the type of physician you are seeing, with lower co-pays for your PCP and higher rates for a specialist. This is much more reasonable, however, than paying out-of-pocket expenses for a doctor visit or lab work and is less-complicated than insurance plans that require you to pay upfront, submit a claim, then wait to be reimbursed.
Although HMOs are generally affordable and easy-to-use, there are some drawbacks to the system. If you join an HMO after already having an established relationship with a physician, you may need to find a new doctor if your current one is not in the network. This can mean starting over with someone new who does not know your medical history. It is also sometimes difficult to find a PCP who is taking new patients, especially in a heavily populated area with a lot of people in the same HMO.
Source: LovetoknowInsurance.com
Basics of PPOs
A preferred provider organization (PPO) also gives its members a network of physicians they can visit for medical services. With PPOs, you do not need a referral or a PCP to oversee your care. This gives you greater freedom in your health care choices and allows you to keep seeing the same physicians you already go to. But, if your preferred physician is outside the PPO network, you will need to pay a higher co-payment for your care.
In most cases, PPOs require you to pay a deductible. This means you will need to pay a certain amount of medical costs upfront before your insurance starts picking up the tab. Like HMOs, PPOs also typically require a co-payment for each medical visit, so you will still have some out-of-pocket expenses even after you meet your deductible.
PPOs offer members different levels of coverage to meet their health care needs. These levels can be modified during enrollment periods and come with different costs. Many of the levels offer extras like chiropractor care, which you do not get with standard insurance.
Source: LovetoknowInsurance.com
Medicaid
Medicaid is the United States health program for eligible individuals and families with low incomes and resources. It is a means-tested program that is jointly funded by the states and federal government, and is managed by the states. Among the groups of people served by Medicaid are certain eligible U.S. citizens and resident aliens, including low-income adults and their children, and people with certain disabilities. Poverty alone does not necessarily qualify an individual for Medicaid. It is estimated that approximately 60 percent of poor Americans are not covered by Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States.
Source: Wikipedia.com
Provider Policy Bulletin
Every insurance company should have a published Diabetes Policy or Coverage Bulletin. It is a detailed explanation of what the insurance will and will not cover for T1D care. Be sure you are always up-to-date as the policy can change without a moment's notice.
Insurance Lingo
There are several health insurance terms to understand:
- Premium
- Deductible
- Co-pay
- Co-insurance
- Out-of-pocket maximum
Your premium is the amount you pay into the insurance plan on a regular basis. If you belong to an employer-sponsored plan, the premium is likely deducted from each paycheck as pre-tax dollars. If you purchase your own health insurance plan, you may have the option to pay your premium annually, quarterly, or monthly. Health insurance premiums vary greatly depending on what medical expenses the plan covers, which doctors you can see, and how much you will have to pay in other ways when you use services.
Your health insurance deductible is the amount that you will have to pay for a claim (such as a surgical procedure or hospitalization, but not routine office visits) before the health insurance pays anything. For example, if you have a $100 deductible and undergo a $1,000 procedure, you will have to pay $100 and the insurance company will pay $900. Increasing your deductible is the easiest way to reduce how much you pay for your premium, although you will be responsible for paying more if you use healthcare services.
Your co-pay is the fixed amount you pay for using routine services like visiting your primary care physician or an emergency room or purchasing a prescription drug. In most cases, the payment is the same regardless of the extent of the visit or the cost of the drug. For example, a plan may require co-pays of $20 for office visits, $100 for emergency room visits, and $15 for generic prescriptions or $30 for name-brand drugs.
Co-insurance is similar to a co-pay, although co-insurance generally applies to less routine expenses, and is expressed as a percentage rather than a fixed dollar amount. Co-insurance is in addition to your deductible. So if your plan has a $100 deductible and 30% co-insurance and you use $1,000 in services, you’ll pay the $100 plus 30% of the remaining $900, up to your out-of-pocket maximum. You may find plans with no co-insurance requirements, some with 20/80 or 50/50 coinsurance, or other combinations.
Your out-of-pocket maximum is an important feature of your health plan because it limits the total amount you pay each calendar year for healthcare including co-pays, deductibles, and co-insurance. If your policy carries a $2,500 out-of-pocket maximum and you get sick and require a lot of healthcare services, the most you will pay in a year is $2,500. After that, insurance picks up the rest of the tab.
Health Insurance Options
You are no doubt very familiar with your child's insurance coverage. If you are not happy with your current plan, other options may exist for you. Be sure to check with your employer about switching plans, if they have more than one, during the next open enrollment period. But be careful and do your homework. Make sure that the new plan does indeed have better coverage for your medical concerns. Get their policy (coverage) bulletin(s) so you have it in black and white.
The ADA site below has an excellent summary of what is available to families living with diabetes.
Money Matters
