Every day patients ask me my opinion on what insurance company offers the best coverage? This is not a simple question to answer. Every company offers various kinds of plans. The factors to weigh when deciding which one to choose are the types of services covered and the costs. When I went to medical school, I never dreamed I would also need a degree in the art of understanding health insurance. Here is a crash course on the terminology that drives us all crazy when we visit the doctor.
1. Copay— Most people know what this is. Your copay is the amount of money you pay the doctor at the time of your visit. It is deducted from the amount the insurance company will eventually pay the physician. Usually, the copay is less for a primary care physician like an internist or family practitioner, and is more expensive for a visit to a specialist, often even your gynecologist. Occasionally, insurance plans will allow you a preventative visit each year with 100% coverage, meaning you will not be responsible for a copay.
2. Deductible— Your deductible is the amount of money you need to pay toward health care expenses before the insurance company will contribute to or take over the remaining cost. Every plan differs in what services apply toward the deductible. Some require you to meet the deductible even for an office visit (ie. You do not have a “copay” only). Others only apply certain procedures, lab tests, radiographic studies, and non-preventative physician services.
3. Coinsurance—This one is tricky. Patients often confuse “coinsurance” and “copay.” Your coinsurance is a percentage of the allowable fees for medical services that you are responsible for. It is not a set amount like a copay. It depends on the services performed and is calculated based on the amount of money the insurance company has agreed to pay the doctor for a particular service based on the provider’s contract with that company. Often a patient needs to meet their deductible before “coinsurance” applies. For example, once the deductible is met, for a patient who has a plan where there is a 20% coinsurance responsibility, the insurance company would pay 80% of the balance after the deductible has been met, and the patient would be responsible for the remaining 20%.
4. Premium—Your premium is the amount of money you pay, usually monthly, for the health insurance plan. Usually this number is lower if you agree to a higher deductible or coinsurance, taking a chance that you may not need many medical services. Higher premiums apply if you want to ensure lower out of pocket costs for the services themselves. Often employers will contribute to a portion of your premium and many times, the premium can be deducted from your paycheck before taxes.
While most offices do their best to verify a patient’s benefits so that there are no surprises, it is ultimately the patient’s responsibility to be informed about coverage. Do NOT take the word of an insurance agent when it comes to purchasing individual plans. Make sure you do your due diligence to read the documents carefully and ensure that your coverage meets your needs.
Finally, stay away from the hospital as much as possible. Any diagnostic testing or procedures that can be offered in the doctor’s office or a free-standing facility will almost always cost you less than at a hospital. Take advantage of Health Savings and Flexible Spending accounts that may be offered by your employers; these allow you to use pre-tax dollars to help you pay for prescriptions and out of pocket costs like copays, deductibles, and coinsurance.
It’s complicated! Ask questions and be informed!
Dr. Karmin is a Board Certified Ob/Gyn in private practice in Miami, Florida. Call 305-670-0010 or book appointments online at www.miamiwomencare.com.
