Understanding Your health insurance policy
Upon your first visit please provide Inland Artificial Limb and Brace with all Insurance cards including secondary insurance as well as Medicare or Medicaid cards even if benefits were assigned to another medical group. Inland Artificial Limb and Brace will check your benefits and eligibility prior to your appointment to determine if your coverage is active and determine your estimated patient responsibility, however, this is just an estimate.
In some cases, the information provided by your insurance company is inaccurate and may result in a bill or a refund depending on the EOB (explanation of benefits) provided by your insurance after billing and payment is received. In certain circumstances, when verifying insurance, we are told service is covered and then after delivering the item and submitting the bill to the insurance, they deny the service as a non-covered benefit.
Should that occur, you will be responsible for payment for services provided. You may be able to appeal this decision and be reimbursed by your insurance.
However, please be assured, Inland Artificial Limb and Brace will exhaust all appeal options prior to sending you a bill for services in these cases. Please note this process may take some time. We are here to help explain this process if needed. Payment options may be available, please ask for assistance if needed.
Below you will find some helpful information. We thank you for considering Inland Artificial Limb Brace for your Prosthetic and Orthotic needs.
Let’s begin with a few key definitions. Understanding important terminology pertaining to health insurance is the first step to obtaining a cost-effective coverage plan that serves all your individual or family needs.
- Premium:The amount you pay your insurance company for health coverage each month or year.
- Deductible:The amount of money you must pay out-of-pocket before coverage kicks in. Deductibles are usually set at rounded amounts (such as $500 or $1,000). Typically, the lower the premium, the higher the deductible.
- Coinsurance:The amount of money you owe to a medical provider once the deductible has been paid. Coinsurance is usually a predetermined percentage of the total bill. If the policy’s co-insurance is set at 15% and the bill comes to $100, the policy-holder owes $15 in co-insurance.
- Co-pay:This type of insurance plan is similar to co-insurance, but with one key exception: rather than waiting until the deductible has been paid out, you must make their copayment at the time of service. Most often, copayments are standardized by your plan, meaning you’ll pay the same $30 each time you see a physician, or the same $50 each time you see a specialist.
- Out-of-pocket maximum:The amount of money you pay for deductibles and coinsurance charges within a given year before the insurance company starts paying for all covered expenses.
- In-network:This term refers to physicians and medical establishments that deliver patient services covered under the insurance plan. In-network providers are generally the cheapest option for policyholders. Insurance companies typically have negotiated lower rates with in-network providers.
- Out-of-network:This term refers to physicians and medical establishments not covered under your insurance plan. Services from out-of-network providers are usually more expensive than those rendered by in-network providers. This is because out-of-network providers have not negotiated lower rates with your insurer.
- Pre-existing condition:Any chronic disease, disability, or other condition you have at the time of application. In some cases, symptoms or ongoing treatments related to pre-existing conditions cause premiums to be higher than usual.
- Waiting period:Many employer-sponsored insurance plans mandate a period of 90 days before employees can enroll in their insurance plans.
- Enrollment period / open enrollment:The window of time during which you can apply for health insurance or modify a plan to include your spouse and/or children. Policy-holders are unable to adjust their plan until the next open enrollment unless they experience a qualifying life event. These include a marriage, divorce, birth of a child, changes to individual/household income, or interstate residence relocation.
- Dual coverage:The act of maintaining a health plan with more than one insurer. For example, many married people receive coverage from both their employers and their spouse’s employer. Others may opt to receive individual coverage from more than one insurer.
- Coordination of benefits:This process is applied by individuals who have two or more existing policies to ensure that their beneficiaries do not receive more than the combined maximum payout for the plans.
- Continuation of coverage:This is essentially an extension of insurance coverage offered to individuals no longer covered under a particular plan; it most often applies to former employees and retirees of companies that offer employee coverage. COBRA benefits (see Group Coverage section below) qualify as continuation coverage.
- Referral:An official notice from a qualified physician to an insurer that recommends specialist treatment for a current policy-holder.
WHERE CAN YOU GET COVERAGE?
In the United States, all health coverage options fall into one of two general categories. You can obtain individual coverage for yourself and/or your families by reaching out to insurers directly or receive group coverage as an eligible employee or student. With the arrival of the Affordable Care Act, the parameters and regulations pertaining to both types of coverage have been altered significantly.
Individual Coverage: Historically, the costs and availability of individual coverage were highly variable. Thanks to the ACA, individual health insurance plans must now cover you regardless of preexisting conditions or health problems. Under this type of coverage, policyholders are allowed to choose their own physicians (regardless of ‘network’). You can choose three coverage pathways:
- Providers within the ACA healthcare exchange
- Providers outside the ACA healthcare exchange
- Policies that provide short-term coverage
Short-term coverage: This option (also known as a ‘gap policy’) is designed for individuals who are uninsured and/or waiting for their individual/group coverage to kick in. This is a cost-effective route for individuals: the eHealthInsurance marketplace lists short-term coverage rates starting at 85 cents per day. However, short-term coverage does not satisfy the requirements of the ACA in most cases, and policy-holders who do not obtain more robust coverage will be penalized for failure to enroll.
Group Coverage: Unlike an individual coverage plan, which requires the policy-holder to pay for the entire premium, group coverage plan premiums are divided between beneficiaries and the institution that facilitates the group coverage (i.e., a company or university). Group coverage plan-holders are bound to a physician network, but they cannot be denied coverage for pre-existing conditions.
Employer-sponsored coverage: Employers usually pay more than 50% of the monthly premium, and may also support premiums for employee dependents (such as spouses and children). Just as there are subsidies available to individuals who obtain insurance through the ACA Exchange, business owners may be entitled to tax benefits for providing group coverage.
Compared to individual coverage, group coverage plans tend to be much cheaper for policyholders because employers bear most of the premium. Employees may choose to shop for health coverage within or outside the ACA Exchange, rather than obtain an employer-sponsored plan, but, generally, group coverage is the most cost-effective option. One notable exception might be for individuals who pay regular visits to a specialist classified as out-of-network, or those who require prescription medication not covered under the employer plan.
YOUR PLAN OPTIONS
Once you’ve determined the type of coverage that meets your individual or family needs, you need to choose a suitable plan structure. This process can be confusing, as there is significant overlap between different plans, as well as a considerable amount of ‘fine print’ pertaining to each option. The following section discusses some of the most common health plan structures available to U.S. residents.
- An HMO is an organization that requires policyholders to select a primary care physician (PCP) and then only receive treatment and care from physicians and specialists within the established provider network.
- The PCP is responsible for coordinating the plan-holder’s treatment and care services. Plan-holders must receive a referral for most specialist care services.
- Visiting a physician or specialist not designated by the PCP may result in paying all expenses out-of-pocket.
- An HMO plan is generally recommended for those who do not have preexisting conditions that require a physician or specialist other than the appointed PCP.
- The PPO is nearly identical to the EPO. The only major difference pertains to out-of-pocket expenses that stem from visiting out-of-network providers.
- PPOs cover these visits at a higher rate than visits to in-network providers, whereas EPOs do not cover visits to out-of-network providers at all.
- If you require regular visits to physicians or specialists outside your plan’s network benefit the most from a PPO.
- A PCP must be appointed under a POS plan, and means you may only visit other physicians or specialists after receiving a referral from your physicians.
- You may also receive a referral from your PCP to visit doctors outside the established network.
- Out-of-pocket expenses are usually higher, but those who require regular visits to out-of-network physicians and specialists still receive some coverage.
- If you’re insured under a plan with a high-deductible you may be able to open an HSA, an account used solely to save money that is used for future medical expenses.
- Monies distributed from an HSA used for medical expenses of the account-holder or his/her dependents are non-taxable
- Disbursed monies not used for medical expenses must be included as part of your gross income on your tax return and may be subject to an additional tax penalty of 20%.
- After the age of 65, account-holders may withdraw all funds in the account with no tax penalty.
- An FSA is similar to an HRA in that both are tax-advantaged savings accounts established by your employer.