GRAND RAPIDS, Mich. -- Open enrollment is here for medical insurance (YAY), and that means it's time to get informed.
But let's be honest, those big packets of information are enough for some of us to want to pull our hair out.
David Quinn, the director of sales and client services at Priority Health, has healthcare down to a science, but he knows for the average person, the terminology is confusing at times.
Understanding costs can be tough, especially when it comes to the difference between preventative and diagnostic care.
Preventing disease before it starts is critical to helping people live longer, healthier lives and keeping health care costs down.
Preventive care services are at no cost to Priority Health members, including:
- Immunizations or vaccines, like flu shots
- Physical exams
- Some lab tests
- Some prescriptions
One key thing to keep in mind is that you need to make sure the provider you see is in your health plan’s network. At Priority Health. you can check by going to priorityhealth.com and selecting the “find a doctor” tab on the homepage.
While preventive care is free to the member, diagnostic care may not be:
- If you're feeling sick or having symptoms when you receive services, the visit is not considered preventive care, and you’ll have to pay your share of the cost.
- If during a preventive checkup or screening, a potential health problem is found and the doctor sends you for more tests, the tests are considering diagnostic, so you’ll need to pay your portion of the costs for the additional tests.
- Here's an example: You schedule your annual preventive checkup with your doctor. While you’re there, the doctor does a routine exam, a number of preventive screenings and gives you a flu shot. Priority Health pays for all these services in full and your portion of the cost is $0. However, if the doctor hears something irregular while listening to your breathing and sends you to get a chest X-ray, your provider will bill you for your share of the cost of the X-ray.
Services are considered diagnostic if you have a chronic disease, like diabetes, and your doctor monitors your condition with tests. Because the tests manage your condition, they are not considered preventive and you’ll have to pay your portion.·
Priority Health members are encouraged to use the Cost Estimator tool, especially for diagnostic services in which you’re responsible for a portion of the costs. It provides your specific out-of-pocket cost based on your plan type for hundreds of medical procedures and prescriptions. You can access Cost Estimator through the MyHealth app.
A deductible is what you pay before the insurer pays, just like your auto-insurance.
"Your coinsurance is that 70/30 after you hit your deductible. Then your co-insurance kicks in, so you pay 30 percent and your health plan pays 70 percent," Quinn said, adding that a lot of times the higher deductible options like an HSA are a better option, even if you have some health issues going on and you know like bronchitis it's going to be coming to an end.
"I love HSAs. I do," Quinn said.
An HSA (health savings account) is an account that's part of your plan where you and your employer can set aside money that you can use on health care, vision and dental costs.
"You could literally go to the store, and you could buy beer with it, but the IRS is not going to like you for that," Quinn said.
"[HSAs] get you thinking about the cost," Quinn said. "That's the big problem, people don't look at the cost. They just look at the service, and if you have a big deductible and you're paying that deductible and you have money in the bank and it's your money funding it -- sometimes employers put something in there, too -- then you think about it. You have to be smart about the money and shop."
Quinn also added that HSAs transfer from company to company, but make sure you read up on the terms.
HMO vs PPO:
HMOs (health maintenance organizations) have flexibility but the flexibility comes at a price. HMOs have one network; if you want to go out of network, you have to get approval. If you have a PPO (preferred provider organization), you don't. You usually pay more per service.
If you do have an HMO, make sure the provider you see is considered in your health plan's network. Quinn suggests calling customer service if you're in doubt during open enrollment.
"If you're healthy, young and indestructible, and you have an HMO HSA with a high deductible, that's a great plan for you," Quinn said.
HMO is a plan that has a panel of physicians who direct the care within your network. But if you go outside of that network, you have to get a referral from the health plan and/or your doctor to do that, according to Quinn.
"You kind of just do that math and figure out what's right for you," Quinn said.