The “Insurance” Dilemma for the New Year!

women-questioning-look-with-question-markAs we turn another year, there are a plethora of insurance questions and information needed when seeing your health care provider:

      1. What is my deductible?
      2. What is my co-pay/co-insurance?
      3. What is my total out of pocket expenses?
      4. What doctors are on my insurance plan?

This process can be a daunting experience if you, the “patient”, do not have the information at your fingertips. Understanding your insurance benefits and having all of this information at the time of your appointment will ensure a pleasant experience and depress any future financial surprises.

Let’s start off with some very important definitions regarding deductibles, co-pay, co-insurance, max out of pocket expenses, and HMO/PPO/POS plans.

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  • Deductibles – can be defined as a specified amount of money that the insured must pay before an insurance company will pay a claim. This amount varies, but can be as low as $500.00 to greater than $10,000.00. All expenses related to the patient’s care are earmarked to the deductible until it has been met. Once met, the patient’s insurance benefits begin to pay for services based on the patients individual policy benefits.
  • Co-Pay – can be defined as a payment made by a beneficiary in addition to that made by an insurer. The amount of a co pay varies and can be from $10.00 up to or greater than $75.00 per visit.
    Co-Insurance can be defined as the percentage of a covered service you as the patient are responsible for. For example, if your office visit totals $200.00 and your co insurance is 20%, the patient would be responsible for $40.00 at the time of the visit.
  • Out of Pocket Max – can be defined as the most a patient will have to pay for covered medical expenses in a plan year through deductible and coinsurance before the insurance plan begins to pay 100% of the covered medical expenses.
  • HMO (Health Maintenance Organization) – one must choose a Primary Care Physician (PCP) from a network of local healthcare providers prior to seeing a specialist. All care is coordinated through your PCP.
  • PPO -an organization that provides health care to people at a lower cost if they use the doctors or hospitals that belong to the organization.
  • POS (Point of Service) – is a type of managed care plan that is a hybrid of HMO and PPO plans. Like an HMO, participants designate an in-network physician to be their primary care provider. Patients may go outside of their provider network for care.


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