Health insurance is incredibly important to ensuring your family’s access to preventative care, emergency services and treatment of chronic conditions. While Triangle Pediatrics provides equal access to our services regardless of payment, we encourage families to obtain health insurance.
When shopping for insurance or making healthcare choices, it's important to understand the differences between traditional insurance plans versus high deductible plans and how they incorporate the following concepts:
- In-network/Out-of-network providers
- Total out-of-pocket expenses
TRADITIONAL INSURANCE PLANS
The deductible is the amount you have to pay before your insurance pays anything. This applies when you get medical care outside your doctor’s office, such as labs, x-rays, or at the hospital. For example, if you have a $500 deductible, and you get $800 of lab tests, you must pay $500 out of pocket before your insurance will pay anything.
A copay is the fixed amount you pay for a doctor visit or to get a prescription, no matter what the total bill is. For example, you may pay a $20 copay for a primary care office visit or a $40 copay for a specialist
office visit; the remainder of the cost of the visit is paid by your insurance company. Copays for doctor visits usually range between $10 and $60. Copays for prescriptions can range from $10 to more than $60. In general, generic medications are associated with lower copays.
Coinsurance is the percentage of the cost for services like labs, x-rays and hospital care which your insurance company will pay after your deductible is met and until you meet your total out-of-pocket maximum. For instance, if you undergo lab tests costing $800 and your policy had a $500 deductible and 80% co-insurance, you would pay the first $500 of the bill and your insurance would pay 80% of the remaining $300. That would still leave you to pay $60 in addition to the $500 deductible. Co-insurance rates can vary from as high as 90% to as low as 50%.
TOTAL OUT OF POCKET
This is the maximum amount of money you would be required to pay in a coverage year. As an example, assume your total out-of-pocket maximum is $2000, you have a $500 deductible, a co-insurance rate of 80%. If you receive $10,000 worth of covered services, you would pay a $500 and 20% co-insurance on the remaining $9500 up to a maximum of $2000 altogether. But remember, some services you desire may not be covered by your policy at all.
IN NETWORK OR OUT OF NETWORK
You insurance company may have special contracts with doctors, labs, and hospitals to provide care at a reduced rate. This group of doctors, labs and hospitals are referred to as “in network” providers. Other “out of network” providers may charge more and your policy may cover their services at a different rate or not at all. Importantly, this applies to hospitals as well, so before you go to a hospital it is important to know whether it is in network or out of network. Your insurance company should have a website where you can get this information.
HIGH DEDUCTIBLE PLANS
High deductible plans use the same financial concepts, but in different ways. The amount of the deductible in these plans is much higher than traditional insurance, sometimes as high as $2500-$5000. With these plans, you pay 100% of ALL of your medical care until you meet your deductible. It is only then that copays and co-insurance begin to help pay for your care. This means that you pay the entire bill for every office visit, every vaccine, every x-ray, and every hospitalization until you meet your deductible. The trade-off is usually much lower premiums than traditional insurance. Often, well care and vaccines are still covered by these plans before the deductible is met.
If your family is healthy, only goes to the doctor once a year for well visits, and doesn’t take any regular medications, then a high deductible plan may be a good choice. However, if your family has someone with a chronic diseases such as ADHD or Asthma, or someone who takes medications every day, or your children are under 2 and may have many office visits and medications, you may be required to spend your entire deductible every year.
Some families prepare for this possibility by setting aside money equal to their deductible early in the coverage year. Many workplaces offer a Healthcare Savings Account (HSA) which allows you to deduct these savings from your paycheck before paying income taxes on the funds. This money can then be used to pay for medical expenses including your deductible, copays and coinsurance.
Health insurance is a complicated business. It is important to do your homework in order to choose the plan that is best for you.
Need Health Insurance?
If you cannot obtain health insurance through your workplace or school, you may benefit from using the health insurance marketplace set up by the Affordable Care Act. You can access this marketplace at https://www.healthcare.gov/get-coverage. Our own insurance and billing specialist is also available to answer your questions at 919-467-5543.