by Stephen Sofer, PhD
If you have health insurance you know how difficult it is to negotiate the health care insurance highway. Answers to these 10 frequently asked questions may help you avoid some of the potholes.
1. What is the difference between traditional health insurance and managed care?
With traditional (indemnity) insurance, you can select any doctor or hospital at the time service is needed. You do not need a referral to see a doctor. Under managed care, doctors, hospitals, and other health care providers contract with the health plan to form networks that deliver health care services. Normally, you will select providers from within those networks to get the maximum coverage available through the health plan. Some managed care plans, such as point-of-service (POS) plans and health maintenance organizations (HMO) require you to select a primary care physician. In an HMO, the primary care physician coordinates your care and refers you to specialists. In POS, the primary care physician has the same function, but you have the option to go directly to a specialist at a lower benefit level.
2. What is a primary care physician and what is their role?
A Primary Care Physician (PCP) provides routine services, coordinates health care services, and provides referrals to specialists and for hospital services. PCPs can be family practitioners, general practitioners, internal medicine practitioners or pediatricians. Some states have legislation that mandates that other providers be permitted to participate as PCPs.
Managed care plans re-establish the role of “family doctor” by encouraging a steady relationship between you and your primary care physician (usually a family practitioner, internist or pediatrician). In addition to knowing and caring about you, today’s primary care physician coordinates any specialty care and services you might need. He or she manages the medical resources available by guiding you through tests and treatments. If you need a specialist, he or she refers you to one as appropriate.
3. How do billing and payment plans work?
With traditional health insurance, providers bill you or your insurance company for each service performed. You typically pay a deductible and percentage of the provider’s fees. You are generally reimbursed for 80 percent of the “customary and usual” charges for covered services. You are liable for additional payment if the fee exceeds the “customary and usual” charges established by your plan.
Under a managed care plan, network providers generally bill the plan for covered services. Non-network providers bill you directly. You usually pay a co-pay (flat fee) for services within the health plan’s provider network. If you use providers or services outside of the network, you may have to pay a deductible and a percentage of the charges or you may receive no coverage at all, depending upon the type of managed care plan you have.
4. How do point of service programs work?
Point of Service Programs (POS) cover medical expenses whether you visit a participating provider or an out-of-network doctor or hospital. You can keep your out- of-pocket expense to a minimum when you see your participating primary care physician for routine care, and when he or she coordinates necessary specialty or hospital care.
You also have the freedom to go directly to a primary care physician, specialist or hospital for medically necessary care any time you wish. If you choose that route, you will be responsible for the deductible and coinsurance outlined in your specific plan. Please refer to your health plan booklet for details.
5. What are the advantages of using participating providers?
Primary care physicians are your key to consistent, high quality medical care. Your primary care physician is familiar with your health and maintains communication about your progress with specialists to whom he or she refers you. This coordination of care helps you to receive the most effective treatment and medical attention. It also guards you from the inconvenience and possible danger of unnecessary and inappropriate medical procedures.
Visiting your participating primary care physician keeps your out-of-pocket expense to a minimum. What’s more, you are fully covered for specialty care and hospitalization coordinated through your primary care physician. Your only cost may be a small co-payment. Please refer to your health plan booklet for details.
6. How does my primary care physician refer me to a specialist?
Referred care promotes communication between your participating primary care physician and participating specialists. When all parties are informed of your medical condition, you receive the most effective and necessary treatment. You’ll also benefit from minimum out-of-pocket expense because only a small co-payment is required.
7. What if a participating provider isn’t available to treat my condition?
Insurance networks are comprehensive, including most recognized specialties. If there is not a particular type of specialty in the network, the member may contact the insurance company for authorization of treatment from a non-participating provider at the preferred benefit level. Treatment from a non-participating provider will be authorized, if the treatment and/or services are not available in network.
8. What are my out-of-pocket costs if I visit a non-participating doctor?
You will be responsible for the deductible and coinsurance specified in your plan. Also, because the physician does not have a pre-negotiated contract with your insurance company, you may be responsible for the balance of the bills. You must then file a claim form for reimbursement.
9. What are “pre-existing conditions” and how do they impact coverage?
A “pre-existing condition” is a health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to enrollment in a new health plan. Some preexisting conditions may be excluded from coverage during a specified timeframe after the effective date of coverage in a new health plan. Plan documents will provide specific information on pre-existing conditions.
10. What is the Health Insurance Portability and Accountability Act (HIPAA) of 1996?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was signed into law on August 21, 1996. This law includes important new protections for millions of working Americans and their families who have pre-existing medical conditions or who might suffer discrimination in health coverage based on a factor that relates to the individual’s health.
HIPAA includes provisions that:
• Limit exclusions for pre-existing conditions • Prohibit discrimination against employees and dependents based on their health status • Guarantee renewability and availability of health coverage to certain employees and individuals For additional information about understanding your health care insurance try the following Web site: www.healthinsurance indepth.com/
Stephen Sofer, PhD, is program manager of the American Paraplegia Society.
