Choosing the Right Insurance Plan … Some Questions You Should Ask.

Choosing the Right Health Insurance Plan …

Some Questions You Should Ask. 

November 1st is here again and that means it’s time to think about your health insurance—it is the first day of the “Open Enrollment Period”, which lasts until January 31, 2016.  You can change your existing plan or enroll for the first time during this period. 

First and foremost -  DON’T Believe It When They Say:  “All plans offer the same essential health benefits”.  There are important questions to ask to see whether the insurance plan is right for you!  While it is true that (by law) all the plans offer coverage of some sort for:  doctor visits, prescription drugs, hospital visits, maternity/newborn care, and preventive care … it is still misleading to start ANY sentence with the phrase  “All plans offer the same …” because there is so very little that is the same across all insurance plans.  There are MANY MANY differences between the plans and their coverage that WILL affect your out-of- pocket costs, so it would behoove (wow, I’ve been waiting for a while to use the word for something!) you to dig deeper than just looking at the bare basics when shopping for your insurance plan.  Most people tend to consider: deductible, co-pay for doctor visits, prescription coverage, and the out-of-pocket max – BUT – in order to avoid any unwelcome surprises about your coverage as the year goes on, it’s very important to keep on reading past the basic features.

BUYER BEWARE!  You should know that the least expensive insurance plans are the least expensive for a reason – and sometimes you have to read a bit further into the fine print to know what those reasons are.  One of the less obvious areas in which insurance plans can “cut corners” and save money without drawing too much attention from shoppers, is with coverage (or lack thereof!) for ancillary services, such as physical therapy (PT).  Here are some questions to consider with regard to PT:

  • Do they limit the number of visits?  Many plans limit the number of visits to as few as 20 per year – which can be problematic if you have the type of injury that requires extended rehab, such as a rotator cuff repair which typically requires 12 weeks of post-surgical rehab to achieve the best result.  Or what if you have more than one injury in the course of a year (not unusual at all, either with higher level athletes or adults over 40).  It does not matter at all if the research shows a benefit for having more PT visits or whether your doctor says you should have it – the limit is the limit, unless you want to pay out of pocket.
  • Is There a Deductible for PT Visits?  Even if there is a co-pay for DOCTOR visits, MANY insurance plans won’t begin to pay for any of the cost of PT visits until the deductible is met.
  • What Happens After the Deductible is Met?  At that point, you may still have to continue paying co-insurance (a percentage of the allowable rate) until your out-of-pocket maximum has been met. 
  • If  Co-Insurance is Required, What is the Rate?  This is quite variable, but we often see the patient being responsible for 10-30% of the allowable rate (again, only until the out-of-pocket max is met).  If you have a very high deductible, then you may not have any co-insurance after it’s met—your plan may pay 100%.
  • Is There a Co-Pay for PT Visits?  Even if there is, it’s not necessarily the same as for a doctor visit.  Some insurance companies sneak in an outrageous co-pay for PT visits, (assuming that buyers aren’t like to notice it when they are shopping for insurance, those sneaky devils).  We have seen co-pays as high as $75/visit … that’s a tough one, considering that an effective course of PT often involves visits 2-3x/week. 
  • Does the Co-Pay Apply to a Deductible OR to an Out-of Pocket Max?  In MOST cases with physical therapy benefits, co-pays apply to an out-of-pocket max, but not to a deductible … but there are exceptions.
  • Is MY Preferred Doctor/Physical Therapist In-Network vs. Out-of-Network?  Usually, benefits for in-network providers are better than using out-of-network providers.  SO—if the providers that you like aren’t in-network for the plan you’re looking at, then you can either keep looking OR look at what the out-of-network benefits are, which brings me to the next question…
  • What If MY PT or MD is Out-of-Network? Sometimes the out-of-network benefits  are not much different than the in-network benefits and with other plans, there may not be any out-of-network benefits at all.   (For example in the Omaha area, if employees of Alegent Health System, CHI and UNMC employees choose the HMO option for their insurance, they will not have any out-of network benefits).
  • What is the Out-Of-Pocket Max?  This is an important figure, as it is the amount of money that you need to be able to pay before your insurance takes over completely.

There are so very many types of plans and features, that I could not possibly begin to address all of the unusual arrangements that insurance companies have put together in hopes of appealing to all different consumers and different budgets.  But asking these questions about each plan that you are considering will get you going in the right direction!  Good luck!!

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