Have you heard about the benefits of making healthcare appointments before January 1st? If not, don’t worry! Navigating healthcare costs can feel complex. Our goal today is to provide a digestible guide to some key components of healthcare billing and empower you to make the most of your benefits!
Want the TLDR version? See the recap at the end of the article!
We’re here to help with outstanding bills
First, if you have an outstanding bill, we offer a variety of payment options at Beyond Podiatry. We aim to prevent financial difficulties due to your account balance. Please call us if you have questions or if you’ve delayed making an appointment because of your balance. You are an important part of our community and we’re here to help!
Maximizing end-of-year benefits
As 2024 draws to a close, many people find they’ve already met their deductible or out-of-pocket maximum. This means you can take advantage of reduced costs for additional healthcare services before the year ends. Consider scheduling:
- Custom Orthotics and Durable Medical Equipment (DME)
- Routine Visits
- Follow-up Appointments
- Elective Procedures
- Purchasing Necessary Medications
If you need help determining your end-of-year benefits, please reach out to your local Beyond Podiatry office. We’re happy to help!
Types of out-of-pocket costs for folks with private insurance
You may be hit with costs before, during or after any type of visit with a healthcare provider. A good understanding of what drives patient responsibility is important not only to understanding your bills from providers, but also choosing which healthcare plan might be right for you. The majority of the US has employment-based health insurance coverage. Here is a quick guide to what kind of costs you might expect if you are insurance through your employer.
Premiums: This is the amount you pay each month for your insurance plan. Think of it as your membership fee to access health coverage. The amount of your premium will vary by plan with higher premium plans typically offering more coverage and lower premium plans typically coming with higher out of pocket amounts. The premiums you pay are not applied toward your deductible, coinsurance or any individual or family out-of-pocket maximums. The amount of your premium is subject to change annually.
Deductibles: This is the amount you need to pay out-of-pocket for your healthcare before your insurance starts to cover costs (not before you’re treated). For example, if you have a $1,000 deductible, you’ll pay for the first $1,000 of covered services yourself. There are a number of misconceptions about deductibles. The most common is that the amount applied toward your deductible is based on what’s billed for services rendered. Actually, what’s called the allowed amount is what drives how much of your deductible is met for each service rendered.
Allowed Amounts: This is the maximum amount your insurance company will pay for a covered healthcare service. It’s also known as the “negotiated rate” or “eligible expense.” Allowed amounts agreed upon by your provider and insurance carrier.
Copayments (Copays): These are the fixed amounts you pay for specific healthcare services. $20 for a doctor visit, $50 for an ER visit or $10 for a prescription are common – but copays vary by plan.
Coinsurance: This is the percentage of costs you pay for a covered healthcare service after you’ve met your deductible. For example, if your coinsurance is 20%, and the allowed amount for your procedure costs $100, you’ll pay $20.
Out-of-Pocket Maximum: This is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
Balance Billing: This occurs when a healthcare provider bills you for the difference between their charge and the amount your insurance has allowed. Balance billing is generally prohibited when the Healthcare provider is in network with the insurance carrier.
Medicare and Out-of-Pocket Costs
Medicare is the federal health insurance program for people aged 65 and over, and for some younger individuals with disabilities. Here’s a look at out-of-pocket costs in Medicare.
NOTE: Balance billing is prohibited under Medicare plans.
Part A (Hospital Insurance): Typically, there’s no monthly premium if you’ve worked and paid Medicare taxes for a certain amount of time. However, there’s a deductible for hospital stays, and coinsurance for longer hospital stays.
Part B (Medical Insurance): You pay a monthly premium, a yearly deductible, and after your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services.
Part C (Medicare Advantage): These are plans offered by private companies that contract with Medicare. Costs and coverage can vary, but you typically still pay a monthly premium along with some copayments or coinsurance.
Part D (Prescription Drug Coverage): This involves a monthly premium, yearly deductible, copayments, and coinsurance for prescription drugs. There’s also the infamous “donut hole,” where you may pay a higher percentage of drug costs after you’ve spent a certain amount.
Recap:
End-of-Year Benefits: Consider scheduling necessary healthcare appointments before January 1st if you’ve met your deductible or out-of-pocket maximum to take advantage of reduced costs.
Premiums: Monthly membership fee.
Deductibles: What you pay before insurance kicks in.
Copayments: Fixed amounts for specific services.
Coinsurance: Percentage of costs after the deductible.
Out-of-Pocket Maximum: Your financial ceiling.
Allowed Amounts: The maximum amount your insurance will pay for a covered service.
Balance Billing: The difference you may be billed for by a provider if their charge exceeds the allowed amount (usually prohibited for in-network providers).
By understanding these different components, you can better plan your healthcare expenses and take full advantage of your benefits. Never hesitate to contact the Beyond Podiatry team if you need any help navigating this tricky territory.