Your Potential Health Insurance Gaps
As you clip your boots into your bindings and prepare to head down that black diamond for the first (or 100th) time, the last thing on your mind should be what a tumble down the slopes might cost you. This three part series will help you find your potential financial gap areas so you can be prepared to take on your next adventure without worry.
The first part of this series will outline how to find potential gap areas in your health insurance. In part two, we will take a look at what an accident can actually cost you out-of-pocket, even if you have health insurance. Finally, in part 3, we will look at the often overlooked expenses associated with an accident that are not related to the cost of care.
Understanding Health Plans
Just because you have health insurance doesn’t mean that all of your medical expenses will be covered. When assessing where you may have gap areas, you first need to understand what your health insurance will and won’t cover.
If you aren’t familiar with what benefits your insurance offers, that’s OK! Go ahead and pull out your policy documents as well as your insurance identification card (ID card) and review them as you read.
To begin, do a general sweep of your policy to get an idea of what benefits you have. Is your health insurance plan compliant with the Affordable Care Act, i.e., does it meet the 10 minimum essential requirements to be considered a full coverage health insurance plan? Many short term and temporary health insurance policies do not. If you are unsure, check to see if your policy includes the minimum essential health benefits outlined below. These will be listed in your policy documents under a schedule of benefits or policy summary. Some policies also list out specifically what services are not covered. If your policy has this section, it may be helpful to start there.
The 10 Minimum Essential Health Benefits include:
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Ambulatory patient services (outpatient care you get without being admitted to a hospital)
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Emergency services
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Hospitalization (like surgery and overnight stays)
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Pregnancy, maternity, and newborn care (both before and after birth)
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Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
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Prescription drugs
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Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
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Laboratory services
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Preventive and wellness services and chronic disease management
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Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
To find out if you have these benefits, you’ll need to review the documents you get for your health insurance policy each year. Some insurance companies have also created patient logins for you to review your policy documents and benefits online. If you are missing any benefits from the above list, expect to pay for those services completely out of pocket.
It is also important to note that just because a policy states that they provide coverage for certain services, does not mean that the services will be paid in full by your insurance company. There are agreements between healthcare providers and health insurance companies that state how much health services should cost and what the insurance company will pay. Unfortunately, this information is not normally communicated to policyholders before they are seen by a doctor, and any services that are unpaid by your insurance benefits become your responsibility. These additional expenses are what you may have seen billed to you after a doctor’s appointment, even if you already paid a copay or other coinsurance amount at the time of your appointment.
What’s an ID Card?
Remember the insurance ID card I asked you to grab? It should look similar to the example shown below, and will give you a quick snapshot of your deductible, coinsurance, copays, and any prescription drug coverage you have.
Regardless of whether you have an ACA compliant policy or not, you can get a general idea of what you will be expected to pay out-of-pocket for an accident by looking at the following items listed on your ID card:
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Deductible: this is how much you are responsible for paying out-of-pocket before your insurance provider begins paying for services. Some policies begin paying copays or coinsurance depending on the service before a deductible is met, but this will vary by policy and is usually for preventative care or disease management.
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Co-payments**: **also known as copays, are a set dollar amount or percentage (percentages will usually be listed as coinsurance percentages) paid at the time of your appointment, and unless otherwise stated in your policy or on your id card, after your deductible is met. These will often vary with the services being provided. Copays are unique depending on your insurance company and plan type, and can be changed from year to year by your insurance company.
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Coinsurance:** **this is the percentage of the cost of care you will pay after you meet your deductible for services covered by your plan. This percentage will vary based on the plan you have and may be the same for all services provided, or may vary by service. You will pay your coinsurance percentage for the cost of care until you reach your annual out-of-pocket maximum. It’s important to note that coinsurance only applies for covered services. If you are receiving a service not covered under your health insurance plan, you will be responsible for paying the entire amount out-of-pocket.
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Out-of-pocket Maximum (OOP Max): This number is set by the U.S. Department of Health and Human Services (HHS) annually and is different for individuals and families. For insurance plans that are ACA compliant, the maximum amount you should have to pay for covered services in 2018 for individuals is $7,350 and for families is $14,700. This maximum does not apply to services received that are not covered by your health care plan. Yikes.
If you’re having a hard time visualizing how all of these pieces would apply in a real world situation, you’re in luck! Part two of this series will outline how much out-of-pocket the blue health insurance plan above would leave you responsible for after an accident.
See how Buddy’s accident coverage can fit with your health insurance here.
