Preventative health is essential to staying well.
Yet, many people bypass their yearly check-up because they aren’t sure which parts are covered by insurance.
To get the most out of your health insurance, it’s important to understand what is covered for wellness visits.
Tune into SMG Radio to hear health insurance expert Carol Mancusi discuss benefits and you.
Selected Podcast
Benefits 101 – Understanding Benefits and Well Visits
Transcription:
Benefits 101 – Understanding Benefits and Well Visits
Melanie Cole (Host): Preventive health is essential to staying well yet many people bypass their yearly checkups because they aren’t sure which parts are covered by insurance. To get the most out of your health insurance, it’s important to understand what’s covered for wellness visits. My guest today is Carol Mancusi. So, Carol, tell us a little bit about benefits and what does it mean when you say “wellness,” “yearly wellness visits,” and what does it mean to say “benefits”?
Carol Mancusi (Guest): So, a wellness visit really is a preventative visit. It’s a screening. The doctor looks at your overall health to just make sure that you don’t have any problems. It’s a wellness visit as opposed to a problem visit. A benefit would be something that’s covered by your plan. Because of the Affordable Care Act, there are certain preventative visits, services, that are included in most policies at no cost to the patient. There are not out-of-pocket costs. The provider will get paid but the patient should not have co-pay or co-insurance or a deductible applied to these visits for these benefits.
Melanie: What type of visits are covered under that wellness prevention visit?
Carol: An annual physical exam is included for men and women with your primary care doctor; certain blood tests like a cholesterol check, a blood sugar test for diabetes, would be included but other blood tests may not be included. So, it’s not an all-covered type of benefit but it is a basic outline. Every plan has some of that. You should be able to go to your specific plan and see what is covered by your plan for preventative services.
Melanie: What about things like mammograms, pap smears, colonoscopies – are these considered wellness or are they considered special diagnostic tests?
Carol: They are screenings and they can be covered under preventative. Once you go from a screening – screening really means that you have no symptoms, no family history. You’re simply doing a screening to make sure that all is well, once something is found during one of these tests, then it becomes diagnostic and it falls outside of the realm of a screening because now they’ve identified something so the next time you have that service it may not be considered preventive or screening. It would be diagnostic.
Melanie: We always receive a sheet after this called the “Explanation of Benefits”. What is that EOB?
Carol: The Explanation of Benefits is what you receive from your health plan after they’ve processed the claim from your provider and that claim has been closed, basically. They’ve either paid it or denied it. The provider will be paid and the EOB will also show the patients cost sharing: how much of that payment that was allowed for that visit is the patient’s responsibility to pay back to the provider.
Melanie: What do you tell people when they are trying to understand their benefits and they see “80/20” and they see all of these terms and words? How do they know what’s covered under their insurance?
Carol: I think covered and reimbursed are not necessarily the same in today’s world. Maybe ten years ago, if it was a benefit you would say it was covered at 100%. So, you can have a benefit that’s covered by your plan but based on the terms of your plan, it may not be covered at 100%. So that if you have come to the doctor for a dermatology service, let’s say, that office visit or co-pay will apply but if the doctor removes a mole or if he does some other procedure during that visit, that procedure will be billed separately. That procedure may fall under cost sharing for deductible or co-insurance. So, that is where patients really need to know their own benefit and try to figure in those costs when they select the plan during open enrollment. It’s not just about co-pays anymore.
Melanie: Then, how do they figure in if they do have a chronic disease? High blood pressure, diabetes, is there any way for them to sort of figure out what the insurance company will pay for if they have to see their doctor, if they have to go a few times a year to have their blood pressure checked? Can you explain to people how their benefits work?
Carol: Each plan may be different. It’s hard for us when a patient calls us to say is this covered, we can tell them how the payer will reimburse it, but without looking at their plan and knowing the details, which we can do, it’s hard to say exactly how it will be paid. The plans do all have cost estimators. You don’t always need to know the procedure code but you can go to these cost estimators and put in “office visit”; if you know routine blood tests that you’ll get during the course of a visit; if you have a history, you can go back over your EOB’s and look at that. You can put those tests in and it will estimate for you, based on the provider you are seeing, what the patient’s out-of-pocket costs will be. We also help patients with that. We are looking at putting together our own cost estimator so based on our fees and the contracts we have with a different plan, patient’s will be able to ask those same questions and we will be able to get back with them to let them know and give them a pretty good estimate of what those costs will be for certain services.
Melanie: Will that include exclusions and services that a plan does not cover?
Carol: Again, that’s based on specific plans and if it’s a procedure that they know they’re having, we would do that research and get that information so that we could give them a really good estimate close to what will be happening in the office. If we are talking generalities, it’s harder for us to do because certain plans do have exclusions. So, it may not be a covered benefit under certain plans. We would have to do that research with the payer in order to be that specific when we give an answer. Sometimes, we do give an estimate and just ask the patient to go back to their plan to just double-check to make sure that the service is a covered benefit within their specific policy.
Melanie: What does it mean when someone hears “in network” and “out of network”?
Carol: In network means that your provider has an agreement with that payer. We have a contract. We accept the terms of the agreement. We honor the terms of the patient’s plan with that payer. Out of network just simply means that we don’t have a contract with that plan, that insurance company and we are out of network. Some plans will have in network and out of network benefits. If it’s a plan we are not participating in, we are out of network and that plan has out of network benefits, a patient can come to us but out of network deductibles will apply, co-insurance for out of network will apply. Those services, those benefits, are separate from your in network deductibles and co-insurance. It does get confusing sometimes. That’s why when we talk to patients, it’s easier for us to answer a question if they have a specific question in mind. So, we can tell them we’re in network or out of network. We can tell them if we are participating in a particular plan. It’s a little difficult sometimes to narrow it down to the penny when you are just talking generalities because the plans could be slightly different even though they are all from the same insurance company.
Melanie: Carol, in just the last few minutes, please give your best advice for the listeners on maximizing their health benefit dollars and things that you tell people to do to get the most out of their health insurance.
Carol: When you are selecting a plan during this open enrollment period, it’s important to really think about what your needs are. Which doctors do you see? Do they participate in the plan you are thinking of accepting? Do I need a high deductible plan? Is the closed network EPO Plan where you’re limited to the doctors who are participating in that plan, can I save money by selecting that type of plan? Make sure that the hospitals that your doctors use, where they have privileges, and that they are also in the plan. Look at your medications and make sure that they’ll be covered under the plan that you select. Those are really the important things that affect everyone. You will use those things during the course of the year.
Melanie: Thank you so much. You’re listening to SMG Radio. For more information, you can go to SummitMedicalGroup.com. That’s SummitMedicalGroup.com. This is Melanie Cole. Thanks so much for listening.
Benefits 101 – Understanding Benefits and Well Visits
Melanie Cole (Host): Preventive health is essential to staying well yet many people bypass their yearly checkups because they aren’t sure which parts are covered by insurance. To get the most out of your health insurance, it’s important to understand what’s covered for wellness visits. My guest today is Carol Mancusi. So, Carol, tell us a little bit about benefits and what does it mean when you say “wellness,” “yearly wellness visits,” and what does it mean to say “benefits”?
Carol Mancusi (Guest): So, a wellness visit really is a preventative visit. It’s a screening. The doctor looks at your overall health to just make sure that you don’t have any problems. It’s a wellness visit as opposed to a problem visit. A benefit would be something that’s covered by your plan. Because of the Affordable Care Act, there are certain preventative visits, services, that are included in most policies at no cost to the patient. There are not out-of-pocket costs. The provider will get paid but the patient should not have co-pay or co-insurance or a deductible applied to these visits for these benefits.
Melanie: What type of visits are covered under that wellness prevention visit?
Carol: An annual physical exam is included for men and women with your primary care doctor; certain blood tests like a cholesterol check, a blood sugar test for diabetes, would be included but other blood tests may not be included. So, it’s not an all-covered type of benefit but it is a basic outline. Every plan has some of that. You should be able to go to your specific plan and see what is covered by your plan for preventative services.
Melanie: What about things like mammograms, pap smears, colonoscopies – are these considered wellness or are they considered special diagnostic tests?
Carol: They are screenings and they can be covered under preventative. Once you go from a screening – screening really means that you have no symptoms, no family history. You’re simply doing a screening to make sure that all is well, once something is found during one of these tests, then it becomes diagnostic and it falls outside of the realm of a screening because now they’ve identified something so the next time you have that service it may not be considered preventive or screening. It would be diagnostic.
Melanie: We always receive a sheet after this called the “Explanation of Benefits”. What is that EOB?
Carol: The Explanation of Benefits is what you receive from your health plan after they’ve processed the claim from your provider and that claim has been closed, basically. They’ve either paid it or denied it. The provider will be paid and the EOB will also show the patients cost sharing: how much of that payment that was allowed for that visit is the patient’s responsibility to pay back to the provider.
Melanie: What do you tell people when they are trying to understand their benefits and they see “80/20” and they see all of these terms and words? How do they know what’s covered under their insurance?
Carol: I think covered and reimbursed are not necessarily the same in today’s world. Maybe ten years ago, if it was a benefit you would say it was covered at 100%. So, you can have a benefit that’s covered by your plan but based on the terms of your plan, it may not be covered at 100%. So that if you have come to the doctor for a dermatology service, let’s say, that office visit or co-pay will apply but if the doctor removes a mole or if he does some other procedure during that visit, that procedure will be billed separately. That procedure may fall under cost sharing for deductible or co-insurance. So, that is where patients really need to know their own benefit and try to figure in those costs when they select the plan during open enrollment. It’s not just about co-pays anymore.
Melanie: Then, how do they figure in if they do have a chronic disease? High blood pressure, diabetes, is there any way for them to sort of figure out what the insurance company will pay for if they have to see their doctor, if they have to go a few times a year to have their blood pressure checked? Can you explain to people how their benefits work?
Carol: Each plan may be different. It’s hard for us when a patient calls us to say is this covered, we can tell them how the payer will reimburse it, but without looking at their plan and knowing the details, which we can do, it’s hard to say exactly how it will be paid. The plans do all have cost estimators. You don’t always need to know the procedure code but you can go to these cost estimators and put in “office visit”; if you know routine blood tests that you’ll get during the course of a visit; if you have a history, you can go back over your EOB’s and look at that. You can put those tests in and it will estimate for you, based on the provider you are seeing, what the patient’s out-of-pocket costs will be. We also help patients with that. We are looking at putting together our own cost estimator so based on our fees and the contracts we have with a different plan, patient’s will be able to ask those same questions and we will be able to get back with them to let them know and give them a pretty good estimate of what those costs will be for certain services.
Melanie: Will that include exclusions and services that a plan does not cover?
Carol: Again, that’s based on specific plans and if it’s a procedure that they know they’re having, we would do that research and get that information so that we could give them a really good estimate close to what will be happening in the office. If we are talking generalities, it’s harder for us to do because certain plans do have exclusions. So, it may not be a covered benefit under certain plans. We would have to do that research with the payer in order to be that specific when we give an answer. Sometimes, we do give an estimate and just ask the patient to go back to their plan to just double-check to make sure that the service is a covered benefit within their specific policy.
Melanie: What does it mean when someone hears “in network” and “out of network”?
Carol: In network means that your provider has an agreement with that payer. We have a contract. We accept the terms of the agreement. We honor the terms of the patient’s plan with that payer. Out of network just simply means that we don’t have a contract with that plan, that insurance company and we are out of network. Some plans will have in network and out of network benefits. If it’s a plan we are not participating in, we are out of network and that plan has out of network benefits, a patient can come to us but out of network deductibles will apply, co-insurance for out of network will apply. Those services, those benefits, are separate from your in network deductibles and co-insurance. It does get confusing sometimes. That’s why when we talk to patients, it’s easier for us to answer a question if they have a specific question in mind. So, we can tell them we’re in network or out of network. We can tell them if we are participating in a particular plan. It’s a little difficult sometimes to narrow it down to the penny when you are just talking generalities because the plans could be slightly different even though they are all from the same insurance company.
Melanie: Carol, in just the last few minutes, please give your best advice for the listeners on maximizing their health benefit dollars and things that you tell people to do to get the most out of their health insurance.
Carol: When you are selecting a plan during this open enrollment period, it’s important to really think about what your needs are. Which doctors do you see? Do they participate in the plan you are thinking of accepting? Do I need a high deductible plan? Is the closed network EPO Plan where you’re limited to the doctors who are participating in that plan, can I save money by selecting that type of plan? Make sure that the hospitals that your doctors use, where they have privileges, and that they are also in the plan. Look at your medications and make sure that they’ll be covered under the plan that you select. Those are really the important things that affect everyone. You will use those things during the course of the year.
Melanie: Thank you so much. You’re listening to SMG Radio. For more information, you can go to SummitMedicalGroup.com. That’s SummitMedicalGroup.com. This is Melanie Cole. Thanks so much for listening.