This week, I want to talk about your understanding of existing coverage and make sure you understand how to utilize your insurance in terms of copays and deductibles to avoid big bills. It is very important to understand your coverage – what you can expect to pay out of pocket for certain things, and what things go towards your deductible. As an example, if you have Marketplace coverage, routine things such as female wellness checkups, potentially physicals, cancer screenings, mammograms, things like that will generally be covered at 100% and the deductible does not apply. There are no co-payments for those things. (These fall into the ACA guidelines of what has to be covered in Marketplace plans).
What if you need labs done, or you’re sick? Your coverage will determine how much you pay, and whether copays or deductibles come into play. There are some plans out there that are zero deductible, which means everything you do is a copay. In this case, it’s always good to go into your portal and look at what your co-pays are. Knowing your co-pays is very important because unfortunately, doctor’s offices often do not take the time to make sure they’re looking at your exact coverage. They look at your general insurance plan and say “Oh, you’re Oscar, or you’re Blue Cross, yes we cover that, and here’s what you need to pay us.” Here is an example from not too long ago; I have a family that’s on Oscar Zero Deductible. The surgeon said you will owe $1800 for a surgery. They were trying to get the surgery scheduled, and she called me asking if this was correct, and I said, “No, you do not owe $1,800.” I showed her how to pull up the portal. The copay was $300 on their plan. I recommended for she prints out the portal information and give it to your surgeon’s office, explaining that this is what they are supposed to pay.
Sometimes it is more beneficial to you to not use your insurance and to rather be a cash patient. Let’s look at MRI’s charges as an example of this. The reality is if you have a deductible plan, say your deductible is $5000, your MRI is not going to get paid by insurance as it won’t meet the deductible. The best idea may be to pay cash for it. There is a place in town where you can pay $500 for an MRI. The reason I suggest paying cash is because what happens is, if you use your insurance in that case, they’re going to bill $2,400 to your insurance. Insurance is going to say this is all applied to the deductible. There might be some discount depending on where you go. But basically, you’ll be liable for the full amount. And if you’re not going to have any other procedures, and you’re not worried about meeting the deductible, why would you do that? Why would you pay that much? I know you’re paying for insurance and want to use it. But again, the whole point is to pay the least out of pocket that you can. You should utilize insurance for catastrophic events, but you’re not expected to pay for all the small things unless you know you’re going to hit your deductible.
If you’d like to discuss your coverage and the best options for you please don’t hesitate to contact me. You can schedule an appointment on my website.
