Sailing the Seas of Insurance Coverage

by Lauren Sweeney, Office Manager

Since the introduction of the Affordable Care Act, medical insurance has been a hot topic of discussion. Overnight, seemingly, people had to go from having passive knowledge about how insurance works to becoming their own insurance brokers. As our healthcare landscape continues to shift, it's easy to feel out to sea.

So let me introduce you to Sue the Pirate:
Sue is insured through the Pirate Health Network (PHN), and she's got some questions about her plan.

• What services are covered through her insurance?
• Which practitioners are in or out of her network, and what does that mean?
• What can she expect to pay when she seeks out various medical services?

In insurance terms, a service being covered just means that the insurance company has rules in place regarding payment for that service - for example, it may go toward deductible, or the patient may have a copay. Most insurers have rules in place about how they pay for physical therapy, since it's a common evidence-based treatment. If Sue wants to have experimental surgery to have gills installed in her neck so that she can breathe underwater, chances are that her insurance company doesn't have rules about that and she'll be on the hook for the ENTIRE cost.

Okay, so Sue's going to wait on getting those gills, but she is having shoulder pain that she wants to get checked out. She knows that physical therapy is a covered service under her policy, and she knows some providers are in-network with PHN and some are not. Does that make a difference?

Yes and no. If a provider is in-network with a carrier, that means that the carrier has a contract with the provider that helps to manage patient costs. When Sue goes to her doctor to check out her shoulder, her doctor may say that the billed amount of the visit was $100, but if her doctor is in-network with PHN, they may have a rule that states that doctors can only charge $75 for an office visit (this is called the allowed amount). Essentially, Sue is guaranteed a discount for going to an in-network provider.

Just because a provider is out-of-network, however, doesn't mean that a patient shouldn't go there. While it's probable that Sue will pay a little more out of pocket (and some plans have no out-of-network benefits at all, so it's important to know if yours does), out-of-network benefits aren't ALWAYS that different from in-network benefits. Some plans even have a shared in- and out-of-network deductible, which means that the patient only has to meet one deductible for insurance to begin paying expenses.

Oh, that's right - we haven't even gotten to deductibles, coinsurance and copays yet, or what all that might mean for Sue. Don't worry - we'll get to that in our next installment.