One of the worst things that can happen to anyone paying for health insurance is not getting the most out of their benefits, leading to overpaying for visits, medications, and procedures without even realizing it.
There are different reasons that can happen, a few of which we’ll talk about in today’s post.
Not Claiming Available Subsidies
The Healthcare Marketplace often has discounts available for plans you’re reviewing based on your income. But knowing how and when to claim these discounts can be confusing to the casual user, and we talk to folks each year that didn’t know they would’ve qualified for a better plan, or the same plan but paying less.
That can have a ripple effect, where not only are you paying more than necessary on the plan itself, but the pricing may have meant you didn’t opt for a plan that would’ve provided better coverage for your needs. Then you’re paying more for prescriptions or doctor visits all year.
Also, most subsidies are a rough estimate until you select your plan and complete the application process — that’s when your actual discount gets applied. The two amounts can be different.
It’s important to note that the level of subsidy is 100% based on your taxable income and number of dependents in the home.
Officially anyone making under $250,000 is eligible for subsidies. In practice, though, the most beneficial subsidies tend to be for incomes of $75,000 a year or less.
WARNING: Do not claim less income than you need to get the coverage you want, as when you file your taxes you will owe the difference back – its approximately $10/month for every $1000 in income you are off in your estimate.
In other words, try to be as accurate as you can when reporting your income. If you input a number lower than what you actually make in order to get a better discount, it could haunt you at the end of the year in penalties where the marketplace will charge you for the difference of what you did pay versus what they calculate you should have paid, based on your actual income.
Out Of Pocket Expenses and Deductibles
Your deductible is basically the amount of money your plan requires that you’ve paid in for various medical services before the insurance will fully cover everything.
If you have a $5000 deductible and a hospital visit, for instance, that would mean you’d need to pay the first $5000 for that visit before insurance would take over. (Minus any amounts you’ve paid earlier in the year toward that deductible.) Your monthly premium payments do not count toward your deductible or max out of pocket limits.
The thing is, sometimes we talk to folks who have actually already met their deductible for the year, but they didn’t realize it. Somewhere along the way, their care providers and healthcare plan provider didn’t catch it either, and then those folks ended up paying for medications or procedures long after that point those things should’ve been fully covered.
Once they were made aware of it we were able to assist them in getting it straightened out. But since the other parties involved hadn’t made the individual aware of it, they might have continued overpaying the rest of the year otherwise.
Ensuring All Components of Preventative Care Visits Get Submitted That Way
Many health insurance plans cover preventative care, either entirely or at lower copays than other types of medical visits.
Your doctor may elect to run some bloodwork or conduct other tests during a yearly physical, for example. Sometimes, the way that visit gets submitted to the insurance company is that the visit itself was preventative, but the lab tests were separate. When that happens, the patient will receive a bill for the uncovered portion of those tests.
If the tests get rolled into the visit as a whole, the whole thing can usually be billed as preventative care, and therefore covered.
This is another area having a health insurance agent in your corner can help.
Understand Which Scenarios May Constitute “Out Of Network” For You
Sometimes your doctor’s office or other care may make being in a certain system (such as Novant or Atrium Health) make sense. But depending on your location, the hospital you’d go to during an emergency might be out of network.
That may affect the type of plan you’d want to be on, since it’s generally easier to change doctors than to deal with a huge hospital bill that isn’t covered.
On that note, it doesn’t matter if you are in Atrium or Novant systems and have an emergency medical need that places you in a different hospital, perhaps even out of state, the insurance companies will work to get emergency services covered within your insurance coverage limits. So if this were to happen to you and say you haven’t yet met your deductible for the year, you would be billed for your deductible before your insurance would kick in regardless of hospital or emergency room.
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If you’ve dealt with any of these challenges, or would like an advocate to help prevent them from happening, give our team a call today!