As more people are getting a private health insurance plan this year, many for the first time ever, there’s still a lot of confusion about what it all means. Dr. Saggar, the ‘Doctor is In’, is here to help understand a few of the words and phrases you hear being thrown around...
What do you mean by premium?Your premium or rate is what you pay each month for your health coverage. Your rate is based on the plan you select, where you live, your age and tobacco use for yourself and any dependents you may be covering.
What is a copay?
The copay is your share for the upfront cost, as the patient, for getting seen when you go and see a healthcare provider like a doctor or nurse practitioner. It’s usually a flat amount, such as $15 for a primary care visit, $50 to $75 for an urgent care visit, and $200 to $300 for an ER visit.
What’s a deductible?
The deductible is the amount you and your family has to pay before your insurance company actually starts paying for anything. For example, if your deductible is $3,000, that’s what you must pay before the plan will start to pay.
So plans with lower deductibles will have a higher monthly premium, and plans with a higher deductible will have lower monthly premiums.
What is coinsurance?
This word means the share of the health care costs you’re responsible for paying. It’s listed as a percentage. For example, if you choose a plan with 20 percent coinsurance you will pay 20 percent of the cost of care AFTER you’ve reached your deductible.
So what is meant by the ‘out-of-pocket maximum’?
The amount you have to pay each year for health care before it’s covered 100 percent by your plan. This is the most you’ll pay for care during the year. This includes three things: your copays, your deductible and the coinsurance, but not your premiums. In other words, only after you’ve paid (1) your monthly premium and (2) your copay and (3) your deductible and finally (4) your share of the coinsurance - only THEN will your insurance company start paying for your medical care.
Understanding this makes people wonder why they even have insurance to begin with! The answer: it’s important for those catastrophic things that you can never really afford to cut a check for, such as a big heart attack or stroke, getting hit by a truck or getting cancer.
What is a formulary?
A formulary is a list of medicines covered by your health plan. You’ll often pay a lower copay or coinsurance for formulary medicines than non-formulary medicines. This is usually because the insurance company has negotiated lower prices for one drug compared with another, so obviously they want you to choose the drugs that they have to pay less for.
What is my coverage outside of the network?
Most individual plans, but not all, have some kind of out-of-network coverage. This is important if you travel around the country, or if you want more choice. If your insurer has no out-of-network coverage, then you’re as good as uninsured if you go somewhere they don’t want you to go. Plans with no out-of-network coverage are usually the cheapest you can find.
The amount you pay (deductibles and coinsurance) for using out of network providers will be higher than if you receive care in-network. Again, the insurance companies have negotiated lower rates with the network providers, and hence try to steer you towards seeing their ‘favorites’, because it’ll cost them less money.
What is the Direct Care network?
Direct Medical Care, aka DMC, is a capitated model, which a growing number of people are using throughout the country, in an effort to reduce or eliminate their out-of-pocket costs. For a low fixed monthly fee, like $59/month in Saint Louis for example, you can get primary care or urgent care, and never pay a penny for a copay, deductible or coinsurance again, for that particular kind of visit. The good thing is that over 80% of visits are primary care or urgent care, so this really does help cut your costs dramatically.
So, if you get a [much cheaper] catastrophic or bronze insurance plan with a direct medical care plan, then your out-of-pocket expenses are limited to around $700 per year if you can restrict your visits to primary care or urgent care, and things are a lot more predictable.
So why should we get health insurance?
Chiefly because of the serious catastrophic big stuff that could happen.
Our out-pocket-costs far exceed the value we get for them when we use insurance for the ‘small-ticket’ items such as urgent care or most ER visits, but we continue to want to have health insurance as a nation, because we’ve been hypnotized to believe that we are somehow exposed or suffering without it. Prevention of disease for those who are perfectly healthy, in the form of an annual physical with your physician or nurse practitioner, is definitely a good idea, but this can still be done affordably without all the copays, deductibles and so on, associated with health insurance.
In summary, insurance was originally created for big-ticket catastrophic problems, much like car insurance, so we should use it for that. For the small stuff, use a much cheaper option in the form of a Bronze plan plus a monthly plan such as DirectMedicalCareUSA.com
Aren’t doctors supposed to be working for the patient?
In ancient China, the ideal doctor was the one who was able to teach a healthy lifestyle in order to prevent diseases. Doctors got paid when they were successful (in keeping their patrons healthy), not when the patients got sick (which was considered a sign of failure).
So why is it that in our ‘modern’ health care system, we do the exact opposite? When someone is sick, he suffers both physically and financially, and his employer suffers by lost productivity in the workplace. So it’s completely backwards to think that the healthcare provider actually benefits financially from that illness.
Wouldn’t it make sense if we turned that around? Shouldn’t we change that model so that physicians can more easily work to keep people healthy rather than gain from their illness?
Our health care system would in all likelihood work much better if everyone was aligned to do better with the same outcome and the same goal, to keep our patients healthy in the first place.
How can we get the physician (or nurse practitioner) back to working for the patient?
There is actually a new system that fits this model. It’s growing in popularity all across America, and it was popular even before the ACA was introduced and passed.
You might even argue that it’s more pertinent now, with the ACA mandates focused so much on preventative care.
It’s called Direct Primary Care, and it involves the physician receiving a flat monthly fee, either without any extra payments from an insurance company, or actually directly from the insurance company.
Almost all of the complications and hassles of healthcare payments and insurance are removed. By eliminating copays and deductibles and by providing unlimited visits, Direct Primary Care transforms the patient-physician relationship to that of a trusted healthcare advisor.
Many employers see this model as a real solution to lost productivity due to employee illness. There’s a lot of evidence that this really works.
By keeping employees healthy, this up-front preventive care avoids a lot of what we call ‘downstream encounters’. These are expensive tests such as MRIs and CT scans as well as treatments including hospitalization.
By removing obstacles to care such as copays, deductibles, limited office hours and locations, people will be more able and willing to see their primary care provider.
By connecting up-front, they address concerns before they become serious problems.
Insurance or Medicaid administrator?
Some insurance companies have seen the wisdom and benefit of this model and are offering it as an option when you select your primary care provider.
Fewer downstream expenses benefit the health and financial well-being of everyone involved; the patient, the employer, and even the insurer.
Interestingly, this free-market solution is good for state Medicaid administrators as well.
Some are finding that including a DPC provider produces the same benefits for Medicaid. So by doing so, the state taxpayers also win by saving money as well. This is a solution that`s actually good for everybody.
What is this brave new world of healthcare?
There’s now a lot of focus on preventative health care, rather than curative. Keep them healthy, don’t just wait and fix them when they’re broken.
We can do better.
We should be standing and running for prevention, and not just scrambling for the cure.
More and more people are demanding better access to affordable preventative healthcare, not just expensive and often unnecessary tests that follow the typical 7-minute physician appointment.
Instead, physicians should be spending 30 minutes with the patient, really working out the situation and then finding that they often don’t have to order a special test or refer to a certain specialist.
Sometimes it’s just a matter of having the time to sit down and truly connect with the patient.
You can’t do that in a 7-minute visit.
How can people make such changes happen?
Employers can ask their insurance companyand state legislators can discuss it with the various Medicaid administrators.
Everyone should be asking how can they all get more DPC providers in contract in this kind of model.
When the insurers and administrators see the interest, and when they realize that this actually benefits them too, they will not just listen, they’ll act, because they’ll quickly realize that it’s in their interest to act.
For more information, visit DirectYourCare.com, which is a St. Louis home-grown company.
(KPLR) – Dr. Sonny Saggar stopped by the studio to continue talking about the Affordable Care Act.
In the second segment of his three part series, he discussed money and Missouri.
What’s the same in every state?
When it comes to your health care options on the Marketplace, some things are the same in every state such as basic coverage.
The U.S. government sets basic guidelines for what are called ‘essential benefits’. Every health plan sold in the Marketplace has to offer them.
They include emergency care, pediatric care, maternity care, lab testing,and more.
There are upper limits on how much you have to spend before your insurance company starts paying toward your care. No plan can charge more based on your health or whether you’re a man or a woman.
Four levels of coverage
To make it easier to compare plans, every Marketplace will rank the types of plans according to the level of benefits they offer, from platinum (the most) to bronze (the least). There’s also a special plan for young adults.
What decisions can Missouri make?
Aside from those basic requirements, states that set up their own Marketplaces have a lot of control over what to include in their health coverage.
Which insurance companies get to sell on their Marketplace and how many
States can choose insurance companies and can set tougher rules for coverage than the federal guidelines require.
Some states, like California, are limiting the number of insurance companies selling on their Marketplace. They hope it will improve the quality of the plans offered. Other states are taking a different approach. For instance, Colorado will allow any insurance company to sell plans.
Treatments that are covered
States running their own Marketplaces can tell companies that they must make the essential benefits more generous than the federal guidelines.
For example, some plans may pay for weight loss surgery, but others may not. Some plans may cover fertility treatments to get pregnant under maternity care, but others may not.
One plan may only cover a few drugs for your condition, like medicine for high blood pressure, while another plan may cover many brands.
What complementary and alternative treatments count as essential benefits
For instance, some states, like California, Maryland, New Mexico, and Washington, are including acupuncture as an essential health benefit. Many other states probably won’t.
How to promote the Marketplace
States are in charge of advertising for their Marketplaces and encouraging people to use them. That matters. If a state is very successful in getting lots of people to buy plans, the costs of insurance in that state could go down for everyone.
State Marketplaces may offer extra coverage for health problems that are more common in that state. For instance, if a state has high levels of diabetes, its Marketplace might include more plans that have special programs to help people with that condition.
Coverage for more people with low incomes
One way health reform was supposed to help more people get medical care was to expand each state’s Medicaid plan. Medicaid is the free or low-cost health program for people with very low incomes.
However, states can decide whether or not to expand Medicaid. If a state doesn’t expand Medicaid, some low-income people won’t be able to afford coverage. To find out whether you qualify for Medicaid, check out the insurance finder on HealthCare.gov.
Things to know about Missouri’s Marketplace
Plans will vary state-to-state. If you’re trying to help an out-of-state relative buy a plan, remember that their options will be different from yours.
We don’t know all the details yet. What exactly will Missouri offer? Presently, nothing. Missouri has so far decided not to participate in any way in the Affordable Care Act.
The Federally-facilitated Marketplace (FFM) will be offering health coverage in Missouri in 2014. The FFM will make assessments of Medicaid/CHIP eligibility and then transfer the applicant’s account to the state agency for a final eligibility determination. Missouri is not expanding Medicaid coverage to low-income adults effective January 1, 2014.
Physician’s point of view
The healthier our citizens are, the more productive they are. It is as simple as that. You can’t contribute much to society if you are crippled with a foot broken years ago and never repaired properly.
You can’t contribute much if you are burdened by depression or an untreated psychosis or lupus or rheumatoid arthritis. We benefit from the productivity of healthy people.
Furthermore, we benefit from their health itself.
If poor people don’t get checked for tuberculosis, the rest of us are at risk. If poor people don’t get treated for addiction, we all suffer from petty theft to secure them a supply of drugs.
If mental illness isn’t diagnosed and treated early, that burden is for all of us to bear. We pay a lot more to care for the mentally ill in prison than early treatment would cost. And it’s cruel as well as expensive.
Medicaid expansion will benefit those of us who don’t need it, who have health insurance, as well as benefitting those who cannot afford insurance.
But most important as a matter of law, caring for the poorest among us, ensuring that they receive the benefits of good healthcare, is a measure of the quality of our society. Do we harden our hearts and turn our backs? Or do we provide quality care to everyone who needs it?
The important thing to note is that the Affordable Care Act is not as much health care reform as it is insurance reform.
St. Louis Urgent Cares presently has 4 locations in St. Louis, and all 4 are active participants in Direct Medical Care: Downtown Urgent Care, Eureka Urgent Care and Creve Coeur Urgent Care, and North City Urgent Care. We are planning even more facilities in the near future.
This is Part 1 of a 3-Part Segment on Healthcare Reform
1. The Basics
2. Money and Missouri
3. Get Ready
1. The Basics: What You Need to Know About Health Care Reform In Case You Didn’t Know
Many changes take effect starting in 2014.
You’re one of the people that health reform may benefit if:
● You make too little to afford health insurance but make too much or can’t otherwise qualify for Medicaid.
● You have young adult children who need insurance coverage.
● You have an existing chronic or serious health condition, including depression or another mental health concern.
Fewer Limits on Your Coverage
You can have a long-standing health problem (also known as a ‘pre-existing condition’) and still get insurance. No matter how good or bad your health might be, every health plan must let you buy insurance. Plus, having a health problem won’t increase how much you pay for your insurance. This is a big change.
You also don’t have to worry that your health coverage will run out. Insurance companies used to be able to put a yearly or lifetime cap on the amount they would cover. Starting in 2014, your health plan can no longer limit what it spends on your covered benefits each year or in your lifetime. This is another big change. You’ll never “run out” of insurance.
More Affordable Health Plans
Most people are required by law to have health insurance by 2014. But don’t panic – the government has set up new ways to help you. You may be able to buy affordable, even subsidized, insurance through a Marketplace, also called a Health Insurance Exchange or HIE. Every state will have a Marketplace to help you sort out your coverage options and select a plan that best fits your needs. This may help if you don’t have insurance nowor if you have trouble paying for it.
You can begin reviewing your new insurance options right now through your state Marketplace. You can get more information and sign up by phone, in person, or online by visiting www.healthcare.gov. Trained assistants called navigators can answer your particular questions and provide help in signing up. Once you’ve selected a health plan, coverage starts Jan. 1, 2014.
Financial Help to Buy Insurance
In addition to finding a cheaper health plan, you may also qualify for financial help, or subsidies, to help further reduce its cost. You may be able to get a tax credit to lower the cost of your insurance. Whether you qualify for assistance will depend on your income — how much money you think you will make in 2013 — and how many people are in your family. You can find out if you qualify for a tax credit when you apply to buy health insurance through your state’s Marketplace.
Expansion of Medicaid
For others, you might be able to qualify for Medicaid for the first time. In some states, Medicaid is changing its rules because of health reform, and more people will be able to participate. I’ll be covering this in more detail in a later segment because our state has not yet expanded Medicaid.
What’s Already in Effect
Many benefits are already here, but you should check with your health plan about any you’re interested in and haven’t used yet.
● KIDS – Children must be covered by insurance even if they already have a health problem, called a pre-existing condition. If your child develops a chronic condition, such as diabetes or asthma, your insurance still must cover your child.
● ADULT KIDS – You can keep your kids on your existing health insurance longer. As of now, children can stay on your policy until they are 26 years old.
● PREVENTION – You can get some types of care for free. Certain tests and checkups, called preventive services, are now completely paid for by your insurance. These include a well-child visit each year, blood pressure and cancer screenings, and flu shots. This means NO copays and NO deductibles for this preventive care.
● GUARANTEE – You’re better protected by insurance. If you or someone in your family gets sick, your insurance company can no longer cancel your coverage.
● ESSENTIAL HEALTH BENEFITS must be covered by all qualified health insurance plans. These include emergency services, hospitalization, maternity and newborn care, prescriptions, and more.
● PRIMARY CARE PROVIDER CHOICE – You can choose who will be your primary care provider, often referred to as PCP. Your PCP is your lead health care professional — the one you see for screenings and when you’re sick. A PCP can refer you to specialists if you need them.
● APPEALS – You now have an easier way to complain about insurance problems. Each plan must have an appeals process, which are the steps you must go through to ask a health plan to pay for something they said wasn’t covered. Every health plan must tell their members what their appeals process is.
Affordable Primary & Urgent Care Options, without using insurance…
With many employers moving to a high-deductible plan for their employees, there is a grassroots movement called Direct Medical Care or Direct Primary Care, which is similar to concierge medicine for the masses. This means you get “customized” care, but at an accessible and affordable price.
You can find out more at DirectMedicalCareUSA.com, which is the main one in St. Louis. All the St. Louis Urgent Cares facilities actually participate in this program.
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St. Louis Urgent Cares presently has 4 locations in St. Louis: Downtown Urgent Care, Eureka Urgent Care and Creve Coeur Urgent Care, and North City Urgent Care.
Incidentally, the Ribbon-Cutting Ceremony for North City Urgent Care is tomorrow (Tuesday 22nd October) from 9am to 11am, at 6113 Ridge Avenue, 63133. Be there to join in the celebration if you can make it.
St. Louis Primary Care also operates at each of these locations. All eight practices participate in DirectMedicalCareUSA.com
You can get a cholesterol profile and a flu vaccine for no extra charge at each facility whenever you come in as a patient for any illness or injury.
In the state-run health insurance marketplaces, the government-approved health insurance plans are divided into five tiers: platinum, gold, silver, bronze, and catastrophic. Analysts expect young adults to gravitate towards the bronze and catastrophic plans, which are the lowest-cost options.
Both the bronze and the catastrophic plans cover basic preventative health services including cholesterol tests, immunizations and screenings for depression and alcoholism (a full list is here). Both also cover, to varying degrees, all 10 categories of “essential health services”: hospitalizations, emergency services, ambulatory (outpatient care) services, some maternity and newborn care, pediatric care, vision and dental care for children, mental health and behavioral health treatment, rehabilitative and habilitative services and devices, laboratory services, and chronic care services.
There are some key differences between these two tiers, however. This chart can help you decide which plan may be right for you.