What a New Year Can Mean for Your Health Plan

With the New Year fast approaching, it’s high time to talk about health insurance/health plans and what a new year implies. Employers who supply health insurance for their employees or who make it available for purchase typically make any changes at the beginning of the calendar year. So, many of you may find yourselves with a new insurance carrier or a different plan with the same carrier, and it’s important to know how that may affect you financially in the coming year.

More and more employers are reacting to the high cost of health insurance by either choosing plans that are less expensive or by requiring employees to pay a portion of the monthly premium. Very large employers may have several plans for you to choose from, but most will have one plan for all their employees. Whatever your situation, make it a priority to know as much as you can about your plan as soon as you can. For example:

  • Know if you have a deductible, and what that implies. It’s not unusual to have a plan with a $500 or $1000 yearly deductible these days. These plans typically have lower monthly premiums, saving you (or your employer) on the up-front monthly cost, but you will be responsible for that first $500 or $1000 of health care costs. Not all services are treated this way; for example, in many plans, preventive care is covered regardless of whether you have met your deductible. Know how much your deductible is, what costs ‘count’ toward it, and save all of your receipts and EOBs (explanation of benefits) in case you ever need to dispute the issue with your insurance company.
  • Know if your employer offers any way to help with high deductibles, such as a HSA or even reimbursing you for part of your deductible.
  • Know how preventive care is treated. The Affordable Care Act mandated changes in how preventive care is covered. Insurance companies have some leeway in how fast they make these changes, but eventually, preventive visit should be exempt from copays and, for children, allowed on the schedule recommended by the AAP. When this finally takes effect on all plans in the next couple of years, older children will have yearly coverered visits (many plans now only cover them for every other year).
  • Keep on top of your balance, whether it’s at our office or any other medical office. Don’t ignore statements thinking that the charge must be a mistake. Call early if there is a question or if you need to set up a payment plan. Failure to pay medical bills can result in having to find new doctors!
  • Realize that the insurance plan details are an agreement between you and the insurance company. Medical offices aren’t allowed to ‘fudge’ the record so that a non-covered service is covered. We can’t lie and change that cough/cold visit to a checkup after that fact so that it’s exempt from your deductible, or charge you less than the standard fee because of a high deductible. We cannot lower our medical standards and treat an illness over the phone in order to avoid generating a charge for you. We CAN help you navigate the insurance jungle, and even give you tips on dealing with your health plan, and we can set up generous payment plans.
  • Realize that if your child is seen at our office (or in the hospital) by one of us, there will be a charge for that visit and any subsequent visits. This sounds obvious, but often parents ask us to ‘work in’ a sibling for an acute illness, and then are surprised when there is a charge. We charge for all face-to-face provider services, whether or not there was a scheduled appointment. The same goes for hospital visits: the hospital rules require us to see our patients every day that they are in the hospital, and there is a charge generated for each day. This is different from surgeons, for example; they are usually paid a lump sum for a specific procedure (for example, a tonsillectomy) and the follow-up visits are considered to be a part of that service and so usually don’t generate a charge unless they occur outside of a specific window of time.

Whew, that’s a lot! Again, know your plan, and plan ahead if you have a large deductible and anticipate accessing significant amounts of medical care early in the year. Call our billing department for help understanding your bill and to set up secure monthly credit-card payment plans if needed.

Beginning early 2012 United Healthcare and Multiplan will be out of network

Our office has been unable to negotiate a fair contract with United and Mulitplan (PHCS) health plans. Beginning January 2012 our office will be classified as out of network for these plans. Letters will be going out soon to notify our patients with United insurance. Multiplan is a group of several hundred small insurance plans. To see if your plan is part of that network, check your card for Multiplan or PHCS logos.

We will continue to bill both of these insurance plans and any portion of the bill not paid by insurance will be the family’s responsiblity. This may affect your benefits and copays so best to to contact your insurance to understand how this will affect you.

Many companies allow for open enrollment around the beginning of the calendar year so you can evaluate your options. If you don’t like the options available from your company, make sure your human resource department is aware.