Hello friends! When I meet with potential clients to consult with them about their insurance needs, the same few questions keep coming up as we discuss Health Insurance and how it pertains to them.
1. What is a deductible, and how does it apply to me?
Deductible – (in an insurance policy) a specified amount of money that the insured must pay before an insurance company will pay a claim.
So for example, if you go into the hospital and have to have a surgery, which is also called major medical, for items like a MRI, other major tests, or an ambulance ride you would have to meet the deductible. So if your deductible is $1000, you would have to pay that to the insurance company before they would close out your claim. They will bill you for that if it is an emergency.
2. Do I have to pay a copay when I go see my doctor?
Copayment – A fixed amount (for example, $20) you pay for a covered health care service like going to see your primary doctor.
You will pay your copayment upfront, before you see your doctor. In Obamacare, you will most likely pay a $20 or more copayment to see your doctor or specialist. When both you and your health insurance company pay part of your medical expense, it’s called cost sharing. Deductibles, copays are examples.
In Medicare for most plans, you will not pay a copayment for most Medicare Advantage plans, all in one plans. These Medicare Advantage plans combine your Doctor, Hospital and Prescription drugs all in one plan and cost you “zero dollars a month” here in Arizona.
If you are just turning 65, or you are on Medicare/Medicaid give me a call so I can help you review your options.
3. Do I need to get a referral from my primary care doctor to see a specialist?
Most likely you will need to get a referral from your primary care doctor to see a specialist on most HMO Plans. HMO/Health Maintenance Organizations, these types of plans keep Insurance costs down by having a network of doctors for Managed Care.
4. What happens if I go Out Of Network, or my doctor is not in the Plans network at this time?
If you go out of the Insurance Plan network to see a doctor or specialist, it won’t be covered, and you will pay for the total cost of the services. You can go out of network only in an emergency, and it will be covered. The same applies if you go to a hospital for surgery, because you think that is the best hospital in the area, and it is not in the insurance plan network of hospitals, you will have to pay for the total cost of Out Of Network services, this can be expensive. PPO plans – Preferred Provider Organizations, some plans allow you to go out of network to choose a doctor or hospital of your choice.
5. What is Maximum out Of Pocket, or MOOP?
MOOP is Cap or limit placed on your healthcare costs for the year by the insurance company.
For example if your MOOP is $3450 for the year, $3450 is the most you can pay out pocket for your healthcare for the year. For example, if your hip surgery cost $100,000 once you met the first $3450 in a Medicare Plan, the Insurance Company would have to pick up the rest, regardless of the amount. So, if you had to have a foot surgery later in the year after hip surgery, and you met your MOOP of $3450 for the first hip surgery, you would not pay anything for the second procedure. The MOOP automatically resets at the first of year for the insurance plan.
If you are on straight Medicare without a supplement plan, there is no MOOP, so if you go into the hospital for example for a couple of days, Medicare only pays 80%, so you have to come up with 20% on your own, which can be a bill from the hospital for $20,000 or $30,000 or more. Let me show you how to avoid this and save you money. Until next time!
I can be reached, At Peace Of Mind Insurance Group, Larry C. Jones, Phone 602-980-6057, email atpeaceofmindgroup @gmail.com website www. atpeaceofmind.com Please call with any questions! Thanks.