Do you know how a copay works for office visits?

Do you have an office visit copay?  If so...with new healthcare reform, this copay is only applicable for office visits other than preventative care which is covered at 100% by your insurance carrier.

A copy is only to cover the cost of consultation..any and all additional lab work or diagnostic testing falls under a deductible expense.

So, for primary care when you are an established patient, the true cost after insurance can be anywhere from $40-$60 to what you will be billed by the provider.  If you have a copay then this will pick up that cost and is owed at time of service.

By not having a copay you will be billed the allowed amount (negotiated/contracted rate) to which is applied towards the plan deductible, chipping away at your total exposure.

Choosing a plan without a copay can save an insured anywhere from $30-$40/month.  Therefore, when you are billed the premium savings will make up the difference by not having a copay and you receive the benefit of having the expense go against the deductible, where copays do not.

Now, the only time a copay might be beneficial is when the insured is a "new patient" for a specialist or non-specialist.  When an insured is a new patient they will be billed a higher amount than normal.  This can be anywhere from $150 for primary to $300 for a specialist.  Once insurance is presented the cost will drop anywhere from 30-70%.

Once the insured is an "established patient" the cost will be dropped as noted above.  For specialists, an insured can expect to pay anywhere from $50-$80 after insurance.

Most plans now have copays of $20-$35 for primary with $35-$60 for specialists.

For more information please call the shoppe.

-Jordan

New Preventative Care Benefits

For those who have had a health insurance policy issued later than 3/23/2010, effective 1/1/2011 your preventative care benefits are covered at 100% by your insurance company with no annual maximums.

Please click the below link for a list of services that the department of Health and Humana Services (HHS) deem covered.
http://bit.ly/9twrh5

Now, as of late...clients of the shoppe have been receiving bills from their insurance company for their recent routine annual checkup.  Depending on doctors, these visits can cost $150-$260 after insurance.  This is the amount that your Explanation of Benefits (EOB) states you may owe the provider.

When reviewing these EOB's, physicians are coding their claims as medical visits with all lab work being billed as diagnostic.  This leads to the insured receiving a bill for covered expenses.

If this is happens, you must call your provider and ask for them to resubmit claims under the right coding and must include medical records for that day of service.

If you have not had your annual checkup...make sure to notify the providers office to code claims as preventative or routine.

Please feel free to contact the shoppe with any questions on this.

Thanks,

Jordan

Mental Health Benefits

Mental Health benefits are different amongst each carrier in the private market and are a cutback in benefits compared to employer provided coverage.

If you currently are covered through your employer, Mental Health benefits are covered the same as any other illness.  So...if your plan has a copay for office visits (out-patient medical services), than any therapy is covered under the copay...as long as your provider is "in-network"

In the private market Mental Health benefits are not covered the same as any other illness.  Below is a list of how each carrier the shoppe represents covers Mental Health benefits:

Aetna

Does not provide coverage

Blue Cross and Blue Shield of Illinois (BCBSIL)

12 month waiting period if considered a pre-existing condition.  All expenses are subject towards the plan deductible prior to being paid at 50% towards the plans out-of-pocket and after.

Celtic

12 month waiting period if considered a pre-existing condition.  All expenses are subject towards the plan deductible prior to being paid at the selected coinsurance level towards the plan out-of-pocket.

Humana

12 month waiting period, except for prescription drugs.  Separate plan deductible for Mental Health, then paid at 50% towards the plan out-of-pocket and after.

United HealthCare (UHC)

Mental Health benefit is additional premium with no waiting period.  All expenses are subject towards the deductible before being paid at selected coinsurance level towards the plan out-of-pocket.

Please call or email the shoppe with any questions.

Thanks,

Jordan

Office Visit Copay or Not???

Having trouble choosing a plan of coverage?
Do the plans that you can afford not have office visit copays?
Are they limited?

No matter which plan you choose the #1 benefit every member of each carrier receives is that they have access to the provider network.  When you seek service at a "in-network" provider you are subject to the negotiated rate of service, not retail..prior to the plan deductible being met.

The negotiated rate is applied to all covered expenditures.

All plans will cover preventative care services at 100% with no cost obligation to the insured.

So..back to having an office visit copay.

So, if your plan has a copay, then this is a fixed amount, on the negotiated rate, that you will pay for the cost of consultation when visiting a specialist or non-specialist.  The copay amount paid does not apply towards the plan .  Some carriers have 2 separate copay amounts, one for a specialist and one non (lower).

Clicking this office visit claim for a recent specialist visit of mine, will show the final cost I owe the provider after my insurance carrier, BCBSIL, processed the claim.  The retail cost was $170 in which I was only allowed to be billed $71.

If my plan had a copy I would have owed at time of service.  By not having a copay, I am billed this amount by the provider, and when paid, it goes against my deductible reducing my overall risk.

Keep in mind that this visit was for a specialist and I was an established patient.  If I had been a new patient, the retail cost would be close to $300.

Now, when choosing a plan you may notice that the copay amount is the difference in price between a plan without.  So..if you have do not visit the doctor frequently, the premium savings will be enough to cover the cost of your office visit consultation.

For any questions please contact the shoppe.

Thanks,

Jordan

HumanaOne Introduces New Plans Effective 1/22

HumanaOne will begin to offer new plans with more deductible options beginning 1/22/2011.

I have placed links to their new materials on the right side of my blog for your review.

These new plans will have more deductible offerings, plus condition specific exclusion riders.  What does that mean?  For applicants who apply to Blue Cross and Blue Shield of Illinois (BCBSIL) and receive an exclusion on a specific condition, Humana will come and offer a separate deductible for that condition.

Please contact the shoppe with any questions.

Thanks,

Jordan

Considering Dental Insurance?

As of  late many of the insurance carriers that I represent now offer a stand-alone dental plan, not only available with your current health insurance plan.

Before selecting this optional benefit, it is important to understand how dental insurance works.

1. Does your dentist accept the plans terms of service and is he considered to be a "In-Network" or "Out-of-Network" provider.  If your dentist is "In-Network" than the dental plan will provide greater benefits.
2. Preventative Services such as cleanings and X-Rays are covered 100%
3. All plans have a 6 month waiting period for Basic Services (cavities, fillings, extractions) and a 12 month waiting period for Major Services(root canal, crowns, dentures, restorative).  After waiting periods, member pays either 20% or 50% of allowable charges.
4. All costs that are paid out by the insurance carrier are applied towards the plans $1,000 or $1,500 annual benefit maximum

The only way around the waiting periods is acquiring a dental plan from Blue Cross and Blue Shield of Illinois (BCBSIL) that must be taken when applying for a plan of health insurance coverage.  BCBSIL only has a 12 month waiting period for crowns, dentures and restorative.

If your teeth are in great shape and you seek semi annual cleanings, you may want to weigh the cost of coverage to the actual cost you are to pay retail.

If you do not have a dentist, then it might be wise to acquire a plan to cover the cost of your initial "new patient" consultation and cleaning, especially if you plan on going twice a year.

If you just found out that extensive work is needed, your best bet would be BCBSIL since there are not any waiting periods for Basic Services and a few Major Services.  If not BCBSIL, none of the plans will be a benefit.

Fore more information please contact the shoppe.

-The Shoppe

Maternity Coverage in Illinois

Happy Holidays and Merry Christmas!

I hope that the readers of my postings, which are few, had a great holiday weekend :)

As of the past month there have been quite a few inquiries on obtaining maternity coverage in the private market.  Unfortunately, there is only one private health insurance carrier that offers an optional Maternity benefit, Blue Cross and Blue Shield of Illinois (BCBSIL).  This optional benefit must be elected at time of application or on the anniversary date of a current BCBSIL plan.

The benefit is payable after a 12 month waiting period with continual monthly premium payments.  All pre-natal care will be covered after the waiting period to then include delivery and post-natal care.  After the waiting period all covered care will be subject to your plans coverage.  Once post-natal care is completed you will then request to remove the Maternity benefit.

If a plan member with the maternity benefit delivers by Cesarean C- Section and removes the benefit, and is to add the benefit again at plan anniversary, there will be complications.

When applying for the benefit at anniversary, all members of the plan must go through medical underwriting, and until January 1st, 2014 (health care reform), BCBSIL can place condition specific exclusion riders.  For example, BCBSIL would offer the optional Maternity benefit but will place an exclusion on future C- Sections, not covering it at all.

Now...the final thing to mention is the Maternity Benefit that is available with the Illinois Comprehensive Health Insurance Plan (ICHIP).  ICHIP is the state high risk pool and the benefit is available with their Traditional coverage option.  To qualify for this coverage you must not be insurable in the private market or have a private policy that is more costly than the ICHIP.  The optional Maternity benefit has a 9 month waiting period.

For additional information on Maternity coverage please contact the shoppe.

Best,

The Shoppe

BCBSIL has updated their effective date guidelines

Effective 12/1/2010, Blue Cross and Blue Shield of Illinois (BCBSIL) has new effective date guidelines.

You can now request an effective date 2 weeks out from the date you submit your application.  If a decision has not been made within the 2 weeks, your effective date will be on approval, but can not be the 29th, 30th or 31st of the month.

Please contact the shoppe with any questions.

-The Shoppe

Recent Visit to the Emergency Room

Well...not so recent as I am late in keeping up with updating our BLOG.

Back in August I had cut my finger with a knife when I was packing up my apartment.  There was no to much pain but a whole lot of bleeding.  After 20 min of continuous bleeding I decide to visit the Emergency Room (ER) as it was during the middle of the night.

Living in the Gold Coast I chose to visit St. Joseph's which is Resurrection HealthCare.  I was treated right away and during my 45 minute stay I received gel foam to help coagulate the blood on the cut, which was wrapped up with a band-aid.  I was then visited by a physician who went over the gel foam and told me to keep it on for 24 hours and then let it heal naturally.

Two weeks following my visit I received a bill from Resurrection HealthCare for $1072.50 which was for Facility Emergency Services.  The next day I received another bill, this time for Physician Services which was for $196.  This brought my total bill to $1,268.50.

$1,268.50 is the retail cost and is the cost one would be responsible to pay if not covered by health insurance.

Being self-employed I have private health insurance coverage with Blue Cross and Blue Shield of Illinois (BCBSIL), in which I presented my insurance card at time of service.  The plan I have is HSA compatible with an annual $2,600 deductible then 100% coverage after. My plan design leaves me to pay up to the my deductible before BCBSIL is to pay a percentage or all.

Back to the bills....

Once I received all billing from Resurrection I then received two Explanation of Benefits (EOBs) from BCBSIL that went over my recent visit, costs and then showed the allowable amount I was to be billed for these services.  The "allowable amount" also known as the "negotiated/contracted rate" is the amount the provider (Resurrection) is allowed to bill me since they accept BCBSIL and are considered an "in-network" provider.

Another week went by and I then received updated billing from Resurrection requesting the reflected amount on my EOBs.  This final amount is what I owe to the provider and is applied towards my deductible.

The final costs were $521 for Facility Services and $56 for Physician Services, $577 total. This is how health insurance works! 

No matter what my plan benefits are compared to anyone else with BCBSIL this would be the plan members responsibility prior to their plan benefits.

Now....the final thing to discuss is how the plan design of my HSA compatible plan works.  The plan requires that I meet the first $2,600 before BCBSIL is to pay 100% of all remaining calendar year expenses.  I take a monthly medication that costs $46 each time at Walgreens, totaling $552/year that is applied toward my deductible.  With the above ER expense I have applied a total of $1,129 toward the plan deductible.  This leaves me knowing that if anything major happened to me, I would only owe a remaining $1,471 before BCBSIL is to pay 100%.  For the price I pay in premium, I don't find a high deductible plan of coverage without copays to be too bad.

Hope this helps in making a decision towards purchasing a plan or understanding how a plan of coverage works.

Thanks,

-The Shoppe

sliw afternoon and vail kills time at the shoppe

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What does having a low deductible mean?

When referencing a low deductible it is in the line of $500 or $1,000.

These are most likely found when coverage is being provided through your employer.

Having a low deductible only means that you are paying a lower amount prior to your insurance carrier paying a percentage (coinsurance) in which you pay your percentage share towards the plans out-of-pocket expense limit in addition to your plans deductible.  Any copays do not apply to the plan deductible or out-of-pocket.

A lower deductible will come into play better than a high when looking at outpatient procedures that total from $500-$2,000

When faced with a large claim such as hospitalization than a low deductible plan will pay them same when comparing high deductible plans, $2,500 or above, especially with 100% coverage after the high deductible,  The main note is that the higher deductible plan can cost anywhere from 30-40% lower in monthly premium.

When choosing to pay the premium for a low deductible, the insured is making the choice in paying upfront to pay less at time of service.  When choosing a higher deductible, especially HSA compatible, the insured is saving in premium and self insuring themselves for small expenses such as office visits.

Please contact the shoppe with any questions.

-The Shoppe

Late night at the shoppe with vail

Awesome

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Check out The Shoppe on ABCs LiveWell HD

Please make sure to check out The Shoppe on ABCs LiveWell HD
http://bit.ly/livewellhd

Thanks for all your support!

vail

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how your health insurance works

Benefits aside, every plan of coverage no matter the insurance carrier has one common factor; a network of providers.

Providers are considered to be physicians, hospitals, facilities and labs.

Each health insurance carrier provides one or up two networks to choose to participate in, with the larger network costing more in monthly premium.

Providers that are within your plans network have a contract to charge you a negotiated rate in service. This rate can be from 30-70% lower than the retail cost of those services.

So in paying your monthly premiums you are gaining access to a provider network, that when utilized can save substantial amounts of savings by not having health insurance.

So, even by paying additional premium for benefits such as office visit copays the insured is paying that amount on a discounted service. Ir may be wise to learn what the true cost of your office visits are to your internist and adjusy a savings to see if a copay is worth the cost.

- the shoppe

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Applying to IPXP

It has come to out attention that many Illinois residents who are applying for the new state health insurance plan are submitting application without the required documents.

In order to qualify for coverage you must have been denied health insurance by a private health insurance carrier within the past 9 months, was offered private coverage (not accepted) that contained an exclusion rider on your medical condition or must have one of the presumptive medical conditions that must be accompanied by a Attending Physician Statement (APS).

Please call The Shoppe to inquire.

-The Shoppe

Mandatory Preventative Care Benefits

Effective for all major medical health insurance policies sold after 9/23/2010, preventative care services that fall under HHS guidelines are now covered at 100% by health insurance carriers.

Please follow this link to learn more on what services are now covered at no cost to the insured:
http://bit.ly/PrevCare_Benefits 

For more info please call The Shoppe!

Sincerely,

The Shoppe

Illinois guaranteed health insurance plan for pre-existing conditions

Effective Today!!
Illinois will start taking applications for health insurance coverage for individuals who meet the below eligibility requirements:

1. Must be a state resident
2. Must have been uninsured for at least 6 months; and
3. Have a pre-existing medical condition.

For more info on the plan please visit http://bit.ly/new_state_plan

A few simple facts on the plan:

• $2,000 annual deductible
• You then pay 20% until an additional, $2,350 is spent in additional out-of-pocket expenses
• Rx will be covered at 80% to a maximum out-of-pocket of $1,600 to the insured being paid at 20%

The Network of providers in Cook County is Health Link, http://www.healthlink.com/home_participant.asp

You can access a list of doctors and hospitals from this link.  you will want to click the network, "State of Illinois Plan"

Please contact The Shoppe with any questions.

-The Shoppe

Prescription Drug Coverage with Health Insurance

If you are looking to purchase health insurance coverage and are currently taking prescription medications (Rx), then this blog will explain how the most competitive carriers The Health Insurance Shoppe represents will cover your prescription medication.

If you are currently insured (privately) than this will help explain your current prescriptions benefits.

Before I go into explaining how each carrier provides benefits, it is important to note, that as long as there is not an exclusion rider on your plan than you will never pay the retail cost of the drug.  When you purchase prescriptions at a participating pharmacy within your plan you are to pay the negotiated (discounted) rate.  If your plan does not have a copay for prescription drugs then it is best to shop around with local pharmacies to see who has the lowest retail cost and accepts your health insurance.

The second thing to note is all carriers mentioned below, except Humana, will not cover prescription medications for the first year of the plan if they were being used within the 12 months prior to application.

Blue Cross and Blue Shield of Illinois (BCBSIL)


All plans other than the SelectBlue, SelectBlue Advantage and BlueChoice Select with a $500 or lower deductible will require you to pay the negotiated rate of your prescriptions towards your plan deductible.  Once you satisfy the plans deductible you will begin to pay 20% on the negotiated rate towards your plans out-of-pocket expense limit.   Once the plans out-of-pocket expense limit is met the insured will continue to pay 20% The only plan offered by BCBSIL that will begin to cover prescriptions at 100% after the deductible is satisfied, is the BlueEdge HSA with 100% coverage.


The first 3 plans mentioned with a $500 or lower deductible will provide an upfront $10 copay for Generics and will require the member to pay 35% on the negotiated rate for Preferred Brand name drugs and 50% on Brand Name drugs.  The total paid would not apply to the plans deductible.


Aetna


Other than HSA qualified plans, Aetna will provide members with an upfront $15 or $20 copay for Generic drugs then subject the member to pay the negotiated rate on Preferred Brand and Brand Name drugs towards a separate prescription drug (Rx) deductible.  Rx deductibles can range from $500 or $1,000 (depending on plan).  Once the Rx deductible is met, then member will begin to pay a $30 copay on Preferred  Brand drugs and a $60 copay for Brand Name drugs.  The copay paid will not apply to the plan


Depending on the cost of the prescription medication, Aetna may increase your premium to take on the cost against risk.


Humana


Other than HSA qualified plans, Humana will provide members with an upfront $15 copay for Generic drugs then subject the member to pay the negotiated rate on Preferred Brand and Brand Name drugs towards a separate prescription drug (Rx) deductible.  Rx deductibles can range from $500 or $1,000 (depending on plan).  Once the Rx deductible is met, then member will begin to pay a $35 copay on Preferred  Brand drugs and a $65 copay for Brand Name drugs.  The copay paid will not apply to the plan


Depending on the cost of the prescription medication, Humana may increase your premium to take on the cost against risk.


United Health Care (UHC)


Depending on the health insurance plan, UHC will provide members with an upfront $15 copay for Generic drugs then subject the member to pay the negotiated rate on Preferred Brand and Brand Name drugs towards a separate prescription drug (Rx) deductible.  Rx deductibles can range from $250-$1,000 (depending on plan).  Once the Rx deductible is met, then member will begin to pay a $35 copay on Preferred  Brand drugs and a $65 copay for Brand Name drugs.  The copay paid will not apply to the plan


Celtic


Other than HSA qualified plans, Celtic will provide members with an upfront $15 or $20 copay for Generic drugs then subject the member to pay the negotiated rate on Preferred Brand and Brand Name drugs towards a separate prescription drug (Rx) deductible.  Rx deductibles can range from $500 or $1,000 (depending on plan).  Once the Rx deductible is met, then member will begin to pay a $35 copay on Preferred  Brand drugs and a $70 copay for Brand Name drugs.  The copay paid will not apply to the plan


Hope this information helps in making a decision towards purchasing a plan of coverage.

Please call with any questions.

-The Shoppe

Dental Insurance

The Shoppe has been receiving a lot of inquiries in the past couple of months on stand-alone dental insurance.  Stand-alone is coverage that does not need to be purchased at time of acquiring a health insurance plan.

Plan can range from $14-$38/month (for single coverage) and range from HMO to PPO plans of coverage.

What does Dental Insurance cover?
Dental insurance will cover your preventative care which is two annual cleaning and X-Rays that come with.  As long as your dentist accepts your dental insurance you would not owe anything for these services.

Preventative will be the only immediate benefit and you will be subject to a 6 month waiting period for Basic Services and a 12 month waiting period for Major Services.

After the waiting periods you would only be able to receive anywhere from $1,000 - $1,500 at the most in annual benefits, payable by the insurance carrier.

Basic Services
All Basic Services will be subject to a 6 month waiting period other than dental coverage with BCBSIL that must be acquired with a plan of health insurance and begins at $26.55/month for single coverage.  Basic Services include:

• Fillings, resin or amalagram
• simple extractions (not wisdom teeth)

After the waiting period these services are typically covered at 50% or 80% by the insurance carrier with benefits payable to the plans maximum at the negotiated rate of service if in-network or up to the maximum allowable amount if services are rendered at a non-participating dentist.

Major Services

All Major Services will be subject to a 12 month waiting period other than dental coverage with BCBSIL as mentioned prior.  Major Services include:

• Endodontics (root canal / therapy)
• Periodontics (gum surgery / oral surgery)
• Crowns
• Bridges
• Dentures

After the waiting period these services are covered at 50% by the insurance carrier with benefits payable to the plans maximum.

The thought process to getting coverage is that you are paying a premium to receive services after a 6 - 12 month waiting period, but at the same time will receive cleanings at no cost.  If your teeth are in good condition and you maintain cleanings annually or semi-annually than your cost for the cleanings will be lower than the cost of the dental insurance premium.

If you are planning on having basic or major services done in the next 6 months, than dental insurance will not be a benefit unless you acquire a health insurance plan with BCBSIL and elect their dental coverage which does not have waiting periods.

The final thing to note is whether or not your dentist, endodontist or periodontist accept dental insurance.  If they do not, than  it will not be a benefit to obtain dental insurance for the payouts will not be worth the premium paid.

For questions on stand-alone dental coverage please call The Shoppe.

Thanks,

The Shoppe