The healthcare and health insurance world can be confusing! Whether this is the first year you're choosing a health insurance plan for yourself, or you've been in the game for awhile, knowing the basics is helpful.
I’ll be doing a series of articles here to give you some terms to know, basic information, and insight into what to consider while choosing a health insurance plan. The goal is for you to feel more confident in choosing the right health insurance plan. Also, I’ll share some tips and advice for how to get the most out of the insurance plan you have.
Today I’ll be showing you some Terms to Know. These are things you have probably heard of, but maybe don’t know what they are or have a vague understanding. Knowing some of the common terms is a good place to start for a better understanding of your health insurance.
Terms to Know
Premium: This is the amount of money charged by an insurance company for coverage
Deductible: The amount you owe for health care services each before the insurance company begins to pay. Co-pays are designed to help you before the deductible is met.
Co-pay: A copayment, or co-pay, is a fixed amount you pay for a covered health care service. Co-pays are a benefit that kicks in before you meet your deductible. Usually you’ll see this for primary care or specialist office visits or maybe for prescription drugs.
Out-of-pocket maximum: This number is the most you'll pay in medical expenses for the year. After this is met, the health insurance carrier will pay for the rest, except for your monthly premium. This idea of a cost ceiling was instated by the Affordable Care Act.
Network: Group of doctors
PCP: This is a primary care provider; this is a doctor or nurse who you go to for your check-ups once a year or for any general health care needs.
Group or Individual insurance: Group insurance is offered through your employer. Individual insurance is for people who don’t get insurance through their employer.
On April 9, 2018, the Department of Health and Human Services issued their final Notice of Benefit and Payment Parameters for 2019, which describes benefit and payment parameters under the ACA for the 2019 benefit year. Standards in the final rule include cost-sharing limitations, the individual mandate’s affordability exemption and more.
Contact us today to learn how your business may be affected by these changes!
This month's Benefits Buzz highlights the rejected Affordable Care Act (ACA) repeal efforts, explains the new Form I-9 Sept. 18 requirement and provides information on the myRA program shutdown.
We have posted information about HSA's (Health Savings Accounts) here before, and here are some more answers to frequently asked questions from Key Bank. Key Bank is a bank in Boise that you can use to set up an HSA account. Colette Chester is the representative there and can answer more of your questions, as well as help you set up the account.
Key Bank HSA Operations
Direct line is 208-861-1160
The Shandro Group not only provides health insurance and benefits consulting, but we also have a variety of ways to support our individuals and employer groups. We have a library of well-researched resources to keep individuals, employers and employees knowledgable about information relating to healthcare and health insurance. This Compliance Overview is very detailed about Health Savings Account (HSA) contribution rules and tax implications.
Recently our own Kelly Madison moderated a panel for the Southern Idaho Compensation and Benefits Association (SICBA.net) to discuss with local employers Direct Primary Care (DPC) sometimes called Concierge Medicine.
Panel Participants included:
Andrea Axtell, MD, Alliance Concierge Care
Richard Johnson, COO of Pingman Tools
Dr. Mark Grajcar, Assured Direct Care
Direct Primary Care – What is it?
Direct Primary Care (DPC) is a relatively new concept in health care that is gaining traction in the Treasure Valley. DPC restores the time-honored patient-physician relationship. Physicians spend more time with each patient, communicate directly with their patients, and may offer weekend appointments. The patient or employer pays an annual fee to the doctor in return for more personalized care, typically combining much of the primary care services into one affordable, flat-fee package. DPC is not a substitute for health insurance, but rather a complement to major medical plans, particularly HSAs. It can lower utilization costs in an employer medical plan, while providing comprehensive and personalized healthcare to the employee.
The DPC model gives family physicians an alternative to fee-for-service insurance billing, they typically charge a monthly fee (retainer) that covers all or most of the patient’s primary care services including clinical, laboratory, and consultative services… some even offer prescriptions “in-house”. The DPC doctor typically does not bill insurance saving significant time and money spent on those administrative costs.
“I have been working with several DPC docs in the valley regarding their services to employer groups. I am also utilizing this model on a personal basis and have been extremely happy with the concept and my provider, Dr. Andrea Axtell. (Her website, as well as other local DPC docs are listed at the bottom.) I can email or text her with a medical question or concern, or if I call, she picks up the phone. If we need a weekend appointment, or even a house-call, she can accommodate… With the HSAs plan I pay all costs below my high deductible (except for wellness visits). If she recommends a test she can’t perform in her office, she has typically negotiated steep discounts for imaging and diagnostic tests, far below the discounts most insurance companies provide. For example, one test suggested would have been $800+ through the normal channels, but with her referral it was $150, so we saved more than $650 with this one incident! And I still have the option of submitting the claim to my insurance carrier and applying it toward the deductible."
Below are a few excerpts from news stories with a link to the original article if you want to do a deep dive – or give us a call to discuss!
Everyone Should Have a Concierge Doctor
Forbes – Aug 2014
Have you ever wondered why you doctor doesn’t talk to you by phone? Lawyers, accountants, engineers and just about every other professional you can think of discovered that phones are a handy way of communicating with clients almost a century ago. More recently, they turned to email. Why haven’t doctors made these discoveries?
One exception to this rule is what is sometimes called “concierge medicine” or “direct care.” This is practiced by doctors who step outside the traditional health insurance system. In most cases, they give their patients same day or next day service. They talk to their patients by phone and email. If their patients have to go to the emergency room, they are likely to meet them there. They serve as agents for their patients in dealing with the rest of the system: ordering tests, getting appointments with specialists, etc.
Heritage Foundation scholar (this link is long but worth the read if interested) Daniel McCorry Daniel McCorry has produced an excellent summary of what researchers know about concierge medicine.
The economic savings are so great that concierge medicine arguably more than pays for itself… Full Article here: https://www.forbes.com/sites/johngoodman/2014/08/28/everyone-should-have-a-concierge-doctor/#51966ebb6323
Want More Time with Your Doctor? Hire one for $70 or less a month.
Idaho Statesman March 15, 2016
Your health should not depend on your ability to game out the risk of waiting to see a doctor, hoping the $150 you save today won’t set you up for a $15,000 hospital bill in a week.
But for many in Idaho — even those with health insurance — taking such risks is reality. And that is prompting patients and doctors to get creative about making basic medical care affordable… Full article here:
Mar 19, 2017 - It's called direct primary care, and it works like this: Instead of accepting insurance for routine visits and drugs, these practices charge a monthly membership fee that covers most of what the average patient needs, including visits and drugs at much lower prices.
Feb 27, 2017 - Dr. Meyer is part of a small but growing cadre of doctors practicing “direct primary care,” which bypasses insurance and charges patients a monthly membership fee that covers everything from office visits to basic lab tests.
Local Doctors practicing DPC in Treasure Valley:
Dr. Andrea Axtell (this is my personal doctor – Kelly M.)
Dr. Mark Garjcar
Dr. Julie Gunther
The Shandro Group not only provides health insurance and benefits consulting, but we also have ways to support our employers' Human Resources departments or provide HR resources for companies that don't employ HR support. On this blog, we will publish information and articles about topics related to the HR industry. This month's HR Brief discusses the importance of becoming a good listener, explains what "competitive pay" really means and briefly covers proactive cyber security strategies.