Our practice is happy to accept most insurance plans. We are unable to accept the following plans at this time:
- Humana Gold
- Humana HMOX
- Medicare (all plans)
- United w/ID starting w/#1 (Like Oxford)
Patients with the above insurances who want to be seen in the office will be processed as self-pay and will be responsible for payment, in full, at the time of service.
Insurance benefits can be confusing, especially because there are so many different plans out there. Although our office can help you understand your benefits, it is ultimately your responsibility to be aware of your individual plan. Nowadays, there are hundreds of insurance plans and it is impossible for us to know the details of every plan. See below for a description of common terms your insurance company will use and some examples that will hopefully help clarify some of the confusion.
Your health insurance deductible is the amount that you will have to pay annually for healthcare services such as surgical procedures, blood tests, or hospitalizations, etc. This must be paid before the insurance pays anything. For example, if you have a $2500 deductible and undergo three $1000 procedures in a year, you will have to pay the full bill for the first two procedures and $500 of the third.
Your co-pay is the fixed amount you pay for using services like visiting your physician for any office visits (including follow ups) emergency room visits or purchasing a prescription drug. In most cases the payment is the same regardless of the extent of the visit or the cost of the drug. For example, a plan may require co-pays of $20 for your family doctor, $50 for any specialist, $100 for emergency room visits, $15 for generic prescriptions and $30 for name-brand prescriptions. Co-pays are separate from your deductible and do not count toward your deductible total. Our office is a specialist office, unless you are coming in for your annual exam without any other problems.
Co-insurance is in addition to your deductible. If your plan has a $100 deductible and 10% co-insurance and you have $1000 in services, you will pay the first $100 for your deductible and then $90 for the 10% co-insurance up to your maximum-out-of-pocket. There are plans with no co-insurance requirements and plans that range from 10% co-insurance up to even 60% co-insurance or other combinations.
Your out-of-pocket maximum is an important feature of your health plan because it is the limit you pay each year for healthcare, including deductibles, co-pays, and co-insurance. If your policy carries a $2500 out-of-pocket maximum and you require a lot of healthcare services, the most you will pay in a year is $2500. After that, your insurance will pay your services at 100%.
Deductible Versus Out-of-Pocket
The difference between your deductible and your out-of-pocket maximum is important. Out-of-pocket maximum is typically higher than your deductible to account for co-pays and co-insurance. For example, if you hit your deductible of $1000 but continue to go for office visits and paying your co-pay, you will have to do this until you reach your out-of-pocket maximum. At this point, your insurance will then take over and cover everything.
Here are some examples:
- Jane has a plan with a $20 co-pay, a $100 deductible, and a $500 out-of-pocket maximum. She comes into the doctor with abdominal pain and pays her $20 co-pay. She needs an appendectomy that costs $700. For the surgery, she will now be responsible for her $100 deductible and then $380 for her out-of-pocket. This is because her $500 out-of-pocket maximum would be met at this point. ($20 co-pay + $100 deductible + $380 co-insurance.)
- Sally has a plan with no co-pays but a $500 deductible with a 10% co-insurance and a $1000 out-of-pocket maximum. She comes into the office for a visit that costs $100. This $100 will go toward her deductible. She finds out she needs an ultrasound that costs $650. She will be responsible for her remaining $400 of her deductible ($100 deductible for office visit + $400 deductible toward ultrasound.) Then $25 for the 10% of the remaining $250 for ultrasound cost, which will go toward her co-insurance. She now has $525 met toward her out-of-pocket maximum.
If you have any questions regarding insurances accepted by our office, please call us at 513-770-0787 and we will be happy to help you.
Please bear in mind that even if your insurance is accepted, some treatments may not be covered. Please be sure to call your insurance carrier to find out what types of visits and treatments are covered, BEFORE you make an appointment.