Open Enrollment Time!

This is the time of year when patients everywhere are making decisions about their healthcare plans for next year. Here's a few tips that might be helpful when making your decisions. Which plan do you have access to and which plan should you get?

Commercial Plan - these are plans sponsored by an employer and usually are with a major carrier such as Anthem BCBS, UnitedHealthcare, Cigna, or Aetna.

HSA - these are plans sponsored by an employer that come with reduced premium costs but high deductibles

Fair Market Plan - these are plans sponsored by an employer that follow the fair market values of healthcare

Marketplace Plan - these are ACA plans offered to small business owners and private individuals who do not have access to a commercial plan

Non-ACA Plan - these are build-your-own plans sponsored by a third party company offered to private individuals who do not have access to a commercial plan

We focus on preventive and managed care for our patients, so some questions you can ask your insurance agent or employer benefits representative are below:

1. Does the policy have ACA-compliant preventive care (or follow the USPTF guidelines)? We specialize in wellness programs and care and many of these services are fully covered (age and health are contributing factors). This type of coverage allows patients to receive services without co-pays or at full coverage even with HSA plans. Some examples include:

  • Blood pressure, diabetes, and cholesterol tests

  • Many cancer screenings, including mammograms and colonoscopies

  • Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcohol use

  • Regular well-baby and well-child visits, from birth to age 21

  • Routine vaccinations against diseases such as measles, polio, or meningitis

  • Flu and pneumonia shots

You can still receive preventive care with non-ACA plans or grandfathered 3rd party plans but you may have a cost-share component or be responsible for the cost of the entire visit, such as lifestyle counseling.

Some other benefits to consider in making your decisions:

2. Does the policy cover my children or dependents until age 26? A great benefit with ACA-compliant plans is coverage for your dependents until the age of 26, regardless if they are married or are in college. This is a wonderful benefit for young people as they begin their journey into adult life.

3. Does the policy have a pre-existing condition clause? Prior to 2014, patients who had pre-existing conditions could be denied the opportunity to receive insurance benefits. ACA-compliant plans give patients ease of mind knowing that a diagnosis on their health record will not prevent them from having coverage for care for services related to that diagnosis in the future. Beginning in 2020, new policies are emerging that include exclusion of preventive care and pre-existing condition clause (meaning they will not cover services related to pre-existing conditions). You can still receive services but will have to pay out-of-pocket for any costs associated with care.

4. Does the policy have chronic care management (CCM) benefits? We enroll patients in CCM during their initiating visit. Many conditions qualify for CCM including overweight, high blood pressure, anxiety and depression, high cholesterol, chronic kidney disease, diabetes, pre-diabetes, cancer, or many other diseases. Many HSA, marketplace, and non-ACA plans allow for these charges but do not offer coverage. For Medicare and commercial plans, there is usually a co-pay for these services.

5. Does the policy have coverage for remote patient monitoring (RPM)? We enroll patients in RPM during their initiating visit. Patients will receive an RPM benefits letter if their provider writes a prescription for RPM. RPM allows patients to submit physiological metrics throughout the month and is recorded using at-home equipment. Many HSA, marketplace, and non-ACA plans allow for these charges but do not offer coverage. For Medicare and commercial plans, there is usually a co-pay for these services.

6. What type of coverage is there for preventive labs and diagnostic labs? Typically, providers will ask patients to receive preventive labs for their annual preventive exam. If you have a condition, other lab orders may be deemed diagnostic. Diagnostic labs could include additional tests if values on your preventive lab is out of range. A diagnostic lab order can cost up to $2000. We also offer specialized diagnostic labs. Many ACA-compliant commercial, HSA, and marketplace plans will cover preventive labs. These same plans will also cover diagnostic labs, sometimes with a co-insurance (or percent due for total amount charged). Fair market plans often have high deductibles and will determine the average amount for a service and charge that amount to a patient.

Good luck in your search! Please be prepared to show your new insurance card at your appointments in November, December and January. You may schedule a 15 minute appointment to review your benefits if you are uncertain as to your coverage. For high deductible or non-commercial plans, we do collect payment at the time of service.


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