If you are someone who is in need of health insurance, or you pay medical bills, you might have noticed the terminology can be a little confusing. When you get bills for medical expenses, do you understand what a copay is, or what it means when they say you have to meet your deductible, or out of pocket max?
Understanding some of the more important terms can go a long way to helping you get the insurance that will work for you and to help you figure out exactly how much a treatment will cost. It can be tricky to navigate health insurance and healthcare in general.
Marisa Price is a Patient Financial Advocate at Hendricks Regional Health, and she is here to help clear up the confusion and sort through some of the terminology that accompanies health insurance.
Selected Podcast
Clearing Up Common Healthcare-Related Insurance Billing Questions
Featured Speaker:
Marisa Price
Marisa Price is a Patient Financial Advocate at Hendricks Regional Health. Transcription:
Clearing Up Common Healthcare-Related Insurance Billing Questions
Melanie Cole (Host): If you’re someone who’s in need of health insurance, or you pay medical bills, you might have noticed that the terminology can be a little confusing. Understanding some of the more important terms can go a long way to helping you get the insurance that’ll work for you and to help you figure out exactly how much a treatment might cost. My guest today is Marisa Price. She’s a patient financial advocate at Hendricks Regional Health. Welcome to the show, Marisa. So, this a really great topic and something that people have so many questions; so let’s dive right in to some of the terminology. What are copays? People hear that. They say, oh, you’re going to have a copay. What is that?
Marisa Price (Guest): A copay would be a fee that’s charged at the time of your visit. It can be at the doctor’s office, and it can be around like a 25, 30 dollar copay. You can also have them at your immediate care locations and also and then in the ER. You can have a copay there. So, they are fees that are charged every time you would have one of those types of visits.
Melanie: And what is co-insurance?
Marisa: Co-insurance is a percentage that the patient is responsible for, for services. So, for radiology you might have a co-insurance of 10% where the insurance company picks up 90% and then you’re responsible for 10% of that radiology fee.
Melanie: So, I think people confuse those two.
Marisa: They do. Absolutely. Yep, where they think they’re almost interchangeable, and they’re really not because that copay is going to be charged at every visit regardless of how many times you have that visit, whereas, the co-insurance goes towards your out-of-pocket cost. So, you’re going to meet that 10% on that radiology visit until you’ve met your full out-of-pocket cost, and then at that point in time, that co-insurance can go away whereas the copays will never go away.
Melanie: Yeah. You can pay copays just when you take your child for a strep check…
Marisa: Exactly.
Melanie: …or an ear infection check, you might have a $40 copay. So, then what is a deductible because they always say you have to meet your deductible before we’ll pay a certain percent?
Marisa: Correct. So, oftentimes, you have the deductible amount; it varies. It can be as low as 500 as far up to $10,000, depending on your policy, and you will pay that deductible first and then your co-insurances usually kick in. The co-insurances can go towards your deductible amount, but they will also keep happening until your total out of pocket is met. So, that deductible amount gets met first with your co-insurance and then that co-insurance continues to be applied until you’ve met your full out-of-pocket amount, which the out-of-pocket amount includes your deductible and your co-insurances but it does not include your copay.
Melanie: So, just so I understand it. You pay—if your deductible is $500, whatever visits you have, you pay your copays, and you have to pay up to the deductible, and then your co-insurance kicks in, and they pay a certain percent whatever you’ve contracted with the insurance company after the deductible is met, and you pay whatever they don’t pay.
Marisa: Correct. Yes.
Melanie: Over the deductible.
Marisa: Over the deductible.
Melanie: So, you mentioned a couple of times an out-of-pocket max. What is that?
Marisa: Yep. Your out-of-pocket max is the total amount that the patient will be responsible for before your insurance covers you 100%. So, a lot of times you have like an 80/20 co-insurance where you’ll pay 20% of your services. Your insurance will pay 80% of your services until you have paid, let’s just give an example of $3500 for the year. So, say your deductible’s 1,500, you meet that, you’ll have that co-insurance up until you meet that total $3,500. That $3,500 would also include the deductible amount. So, if you have a 1,500 and you have to pay up to 3,500 for out of pocket, you’d have another $2,000 to go before your total out-of-pocket portion was met and then once that portion is met, insurance usually picks up 100% if that’s how your contracted. Some insurances will only ever pay 90/10 or 80/20, so you need to understand your policy on what they will pay, but normally insurance reimburses at a higher rate once that out of pocket percentage is met.
Melanie: Which is why you want to try and meet those kinds of things at the beginning of the year so that the rest of the year insurance picks up more than it doesn’t pick up for things that you might need to have done. Now, what is in-network and out-of-network? What does that mean?
Marisa: In-network is driven by your insurance company and who they contract with for services. So, an in-network provider would be someone who your insurance company will reimburse at a higher rate for you to see those physicians or be seen at that hospital because they have a contract with each other. Out-of-network is someone who your insurance company will still possibly pay for, for you to see, but it’s going to be at a lower percentage rate because the insurance is not contracted with that physician.
Melanie: So you want to try, if possible, to see your in-network providers?
Marisa: Yes, your reimbursement will be at a much higher rate if you stay in-network for providers and hospitals.
Melanie: And how do you find out who’s in your network?
Marisa: Your insurance company is required to provide you a list of your providers. Oftentimes, when you are signing up through your human resources, they will have a booklet that includes in-network physicians and hospital locations.
Melanie: What about preventative services? We’re hearing more and more that some of these are covered and even without a copay or co-insurance.
Marisa: Correct. Preventative services are services where your insurance company wants you to remain healthy, so they offer you services each year that you can have done at no cost to you. Your yearly physical at your physician’s office or your child’s well check and immunizations are covered under that preventative service. For women’s services, or a visit to your gynecologist, or your mammogram, your pap, those are covered as preventative services. Some of them you can use each year, and some of them are on an every two or every five-year period depending on what kind of test it is, and your insurance company will have those guidelines for you.
Melanie: And as of right now, even some services like colonoscopy, because it’s been shown to help actually prevent cancer, is considered a preventative service that you can get.
Marisa: Absolutely. And that is driven based on your family history. You may qualify to have that colonoscopy earlier as a preventative service if your family history shows that you have colon cancer within your family line. They like to find that early because preventative treatment is often so much more effective in treating those cancers. Same thing with the mammogram. You can qualify earlier to have those done. Normally a mammogram is scheduled at 40 years of age and a colonoscopy is scheduled at 50 years of age and then you can have the mammograms every year, I believe, and then the colonoscopies every 10 years.
Melanie: So, now what is coordination of benefits? If somebody is trying to figure out if they’re on their insurance or maybe they’re on Medicare. They’ve got a supplement plan; how do you help them coordinate all their different benefits?
Marisa: That is a tricky one because—it’s so for commercial insurances, where families might be dual insured where mom carries the insurance and dad carries an insurance, too, that goes based on the birthday rule. So, whose ever birthday comes first in the year, say, mom’s is February and dad’s is June, mom’s insurance is going to be primary and then dad’s insurance will be secondary and the primary insurance needs to be informed about that secondary insurance as does the secondary insurance needs to know about that primary so that they can coordinate benefits effectively for the patient.
Melanie: Wow, that’s great information. Something that I’m quite sure so many people did not know about the birthday rule.
Marisa: Yeah.
Melanie: Now, if somebody needs financial assistance with medical bills through Hendricks Regional Health, how can you help them?
Marisa: Hendricks Regional Health has a really generous financial assistance program. It can help patients up to 100% of their total bill if they qualify. So, they can call the main hospital, and they will speak with one of our patient financial advocates. They will give them the paperwork that they can fill out and turn back in and then we go through a little process of approval, and we take bank statements, tax information, how many people are in your family, total income for the year and figure out based on that income if you qualify for services.
Melanie: Marisa, what great information. What a great segment. You are so very informed, and you make this easy to understand. So, wrap it up for us, what you would like people to know about all of this terminology, understanding their explanation of benefits that they get, those EOBs, understanding their medical bills, so they can be their own best health advocate.
Marisa: Well, I would really encourage you to call and ask questions if you have them. If you’re confused on your explanation of benefits, know that Hendricks is always here for you to help explain your benefits to help you meet your most beneficial reimbursement and that we are always willing to answer those questions that you just can’t really come to the conclusion on for yourself. We have very experienced people who know the terminology, and they can help explain all of those difficult terms or confusing terms because so many of them do sound the same. We are definitely here for you to explain those, and we just encourage you to give us a call anytime you need help.
Melanie: Well, it is quite obvious that you are committed to helping patients understand this confusing world of health insurance and medical bills. Thank you so much for being with us today. This is Health Talks with HRH, Hendricks Regional Health. For more information please visit hendricks.org. That’s hendricks.org. This is Melanie Cole. Thanks so much for listening.
Clearing Up Common Healthcare-Related Insurance Billing Questions
Melanie Cole (Host): If you’re someone who’s in need of health insurance, or you pay medical bills, you might have noticed that the terminology can be a little confusing. Understanding some of the more important terms can go a long way to helping you get the insurance that’ll work for you and to help you figure out exactly how much a treatment might cost. My guest today is Marisa Price. She’s a patient financial advocate at Hendricks Regional Health. Welcome to the show, Marisa. So, this a really great topic and something that people have so many questions; so let’s dive right in to some of the terminology. What are copays? People hear that. They say, oh, you’re going to have a copay. What is that?
Marisa Price (Guest): A copay would be a fee that’s charged at the time of your visit. It can be at the doctor’s office, and it can be around like a 25, 30 dollar copay. You can also have them at your immediate care locations and also and then in the ER. You can have a copay there. So, they are fees that are charged every time you would have one of those types of visits.
Melanie: And what is co-insurance?
Marisa: Co-insurance is a percentage that the patient is responsible for, for services. So, for radiology you might have a co-insurance of 10% where the insurance company picks up 90% and then you’re responsible for 10% of that radiology fee.
Melanie: So, I think people confuse those two.
Marisa: They do. Absolutely. Yep, where they think they’re almost interchangeable, and they’re really not because that copay is going to be charged at every visit regardless of how many times you have that visit, whereas, the co-insurance goes towards your out-of-pocket cost. So, you’re going to meet that 10% on that radiology visit until you’ve met your full out-of-pocket cost, and then at that point in time, that co-insurance can go away whereas the copays will never go away.
Melanie: Yeah. You can pay copays just when you take your child for a strep check…
Marisa: Exactly.
Melanie: …or an ear infection check, you might have a $40 copay. So, then what is a deductible because they always say you have to meet your deductible before we’ll pay a certain percent?
Marisa: Correct. So, oftentimes, you have the deductible amount; it varies. It can be as low as 500 as far up to $10,000, depending on your policy, and you will pay that deductible first and then your co-insurances usually kick in. The co-insurances can go towards your deductible amount, but they will also keep happening until your total out of pocket is met. So, that deductible amount gets met first with your co-insurance and then that co-insurance continues to be applied until you’ve met your full out-of-pocket amount, which the out-of-pocket amount includes your deductible and your co-insurances but it does not include your copay.
Melanie: So, just so I understand it. You pay—if your deductible is $500, whatever visits you have, you pay your copays, and you have to pay up to the deductible, and then your co-insurance kicks in, and they pay a certain percent whatever you’ve contracted with the insurance company after the deductible is met, and you pay whatever they don’t pay.
Marisa: Correct. Yes.
Melanie: Over the deductible.
Marisa: Over the deductible.
Melanie: So, you mentioned a couple of times an out-of-pocket max. What is that?
Marisa: Yep. Your out-of-pocket max is the total amount that the patient will be responsible for before your insurance covers you 100%. So, a lot of times you have like an 80/20 co-insurance where you’ll pay 20% of your services. Your insurance will pay 80% of your services until you have paid, let’s just give an example of $3500 for the year. So, say your deductible’s 1,500, you meet that, you’ll have that co-insurance up until you meet that total $3,500. That $3,500 would also include the deductible amount. So, if you have a 1,500 and you have to pay up to 3,500 for out of pocket, you’d have another $2,000 to go before your total out-of-pocket portion was met and then once that portion is met, insurance usually picks up 100% if that’s how your contracted. Some insurances will only ever pay 90/10 or 80/20, so you need to understand your policy on what they will pay, but normally insurance reimburses at a higher rate once that out of pocket percentage is met.
Melanie: Which is why you want to try and meet those kinds of things at the beginning of the year so that the rest of the year insurance picks up more than it doesn’t pick up for things that you might need to have done. Now, what is in-network and out-of-network? What does that mean?
Marisa: In-network is driven by your insurance company and who they contract with for services. So, an in-network provider would be someone who your insurance company will reimburse at a higher rate for you to see those physicians or be seen at that hospital because they have a contract with each other. Out-of-network is someone who your insurance company will still possibly pay for, for you to see, but it’s going to be at a lower percentage rate because the insurance is not contracted with that physician.
Melanie: So you want to try, if possible, to see your in-network providers?
Marisa: Yes, your reimbursement will be at a much higher rate if you stay in-network for providers and hospitals.
Melanie: And how do you find out who’s in your network?
Marisa: Your insurance company is required to provide you a list of your providers. Oftentimes, when you are signing up through your human resources, they will have a booklet that includes in-network physicians and hospital locations.
Melanie: What about preventative services? We’re hearing more and more that some of these are covered and even without a copay or co-insurance.
Marisa: Correct. Preventative services are services where your insurance company wants you to remain healthy, so they offer you services each year that you can have done at no cost to you. Your yearly physical at your physician’s office or your child’s well check and immunizations are covered under that preventative service. For women’s services, or a visit to your gynecologist, or your mammogram, your pap, those are covered as preventative services. Some of them you can use each year, and some of them are on an every two or every five-year period depending on what kind of test it is, and your insurance company will have those guidelines for you.
Melanie: And as of right now, even some services like colonoscopy, because it’s been shown to help actually prevent cancer, is considered a preventative service that you can get.
Marisa: Absolutely. And that is driven based on your family history. You may qualify to have that colonoscopy earlier as a preventative service if your family history shows that you have colon cancer within your family line. They like to find that early because preventative treatment is often so much more effective in treating those cancers. Same thing with the mammogram. You can qualify earlier to have those done. Normally a mammogram is scheduled at 40 years of age and a colonoscopy is scheduled at 50 years of age and then you can have the mammograms every year, I believe, and then the colonoscopies every 10 years.
Melanie: So, now what is coordination of benefits? If somebody is trying to figure out if they’re on their insurance or maybe they’re on Medicare. They’ve got a supplement plan; how do you help them coordinate all their different benefits?
Marisa: That is a tricky one because—it’s so for commercial insurances, where families might be dual insured where mom carries the insurance and dad carries an insurance, too, that goes based on the birthday rule. So, whose ever birthday comes first in the year, say, mom’s is February and dad’s is June, mom’s insurance is going to be primary and then dad’s insurance will be secondary and the primary insurance needs to be informed about that secondary insurance as does the secondary insurance needs to know about that primary so that they can coordinate benefits effectively for the patient.
Melanie: Wow, that’s great information. Something that I’m quite sure so many people did not know about the birthday rule.
Marisa: Yeah.
Melanie: Now, if somebody needs financial assistance with medical bills through Hendricks Regional Health, how can you help them?
Marisa: Hendricks Regional Health has a really generous financial assistance program. It can help patients up to 100% of their total bill if they qualify. So, they can call the main hospital, and they will speak with one of our patient financial advocates. They will give them the paperwork that they can fill out and turn back in and then we go through a little process of approval, and we take bank statements, tax information, how many people are in your family, total income for the year and figure out based on that income if you qualify for services.
Melanie: Marisa, what great information. What a great segment. You are so very informed, and you make this easy to understand. So, wrap it up for us, what you would like people to know about all of this terminology, understanding their explanation of benefits that they get, those EOBs, understanding their medical bills, so they can be their own best health advocate.
Marisa: Well, I would really encourage you to call and ask questions if you have them. If you’re confused on your explanation of benefits, know that Hendricks is always here for you to help explain your benefits to help you meet your most beneficial reimbursement and that we are always willing to answer those questions that you just can’t really come to the conclusion on for yourself. We have very experienced people who know the terminology, and they can help explain all of those difficult terms or confusing terms because so many of them do sound the same. We are definitely here for you to explain those, and we just encourage you to give us a call anytime you need help.
Melanie: Well, it is quite obvious that you are committed to helping patients understand this confusing world of health insurance and medical bills. Thank you so much for being with us today. This is Health Talks with HRH, Hendricks Regional Health. For more information please visit hendricks.org. That’s hendricks.org. This is Melanie Cole. Thanks so much for listening.