Understanding Health Insurance

Understanding the nuances of health insurance is sometimes like trying to decipher inter-planetary orbits … in Chinese. And yet for majority of us, next to mortgages and student loans, it is a vital part of our finances that we need to budget for. Here, I break down some definitions and some particulars about commercial health insurance that everyone needs to know about.

Not All Health Insurance Policies Are Created Equal! … and they are not all “good” either…

There are a lot of limitations and particulars about your health insurance you need to know about. Some restrict your access to a specific group of providers (e.g. Providence providers). Some restrict you to only being seen for a limited amount of time and others limit your coverage by the amount of visits. Then others refuse to pay out without prior authorization first. Before you embark on any healthcare visits, it is important to ask some key questions:

1) Is the healthcare provider I want to see in or out of network?
In-network providers generally are lower in cost to you than out-of-network providers. However, you must weigh in the quality of your visits against the cost you anticipate. There are times when out-of-network providers give you unprecedented quality of service that is worth paying for.

2) How much is my deductible?
A deductible is the amount you would have to pay completely out of pocket before you enjoy the discounts and benefits your insurance company provides. Sometimes copays do not apply to the deductible, so this is good to know.

3) What is my copay/coinsurance?
This is the amount you are liable for per visit. A copay is a straight, even amount per visit; whereas a coinsurance is a percentage of the total bill. So for instance, if the total bill for the visit comes out to $200 and your coinsurance is 20%, you will be responsible for $40 of that visit.

4) How much will each visit cost me?
Unfortunately, for almost all providers, we cannot immediately come up with this accurate amount. Services rendered in healthcare are most usually timed – meaning the amount billed depends on how much time was spent performing the service. Without knowing precisely what the practitioner did and for how long (which is only determined at the end of the day) there is no way to know what the exact bill will be. Additionally, each health insurance company pay out at different rates for different services. The best that most providers can do is give you a rough estimate of what your bill will be – so be sure to ask for this*. This applies to all healthcare providers, including family health visits and ER visits.
* FYI, Stride Strong PT charges a prepayment of $100 per visit for when the deductible is not met.

5) Are there any limitations for my visit?
– Mentioned before, some health insurances request that a prior authorization be made before having some healthcare services are performed. This usually goes by way of a form sent to the insurance company by your provider to request allowance to begin service. Make sure your provider is on top of this and all necessary formalities are made prior to being seen.
– Another limitation commonly set is a referral from your family physician. A slip of paper from your family doctor is all that is needed to be on file to justify the service.
– Visit capitation or allowable dollars capitation limits the maximum you can use in your benefit year. Patients need to watch this closely, because they could be liable for all services rendered above this capitation – which could get very expensive very quickly.

6) What is my Out of Pocket Maximum?
This is the maximum you would have to pay out of pocket for your benefit year. After this number is reached, almost all of your future healthcare visits will be 100% covered by your health insurance – so long as formalities and limitations are respected.

7) When does my benefit year start and end?
This is crucial to know because your benefits will reset after the end date. Meaning, your deductible and out-of-pocket maximum will reset – and so will you capitations.

High Deductible Health Plans
With healthcare costs ever-increasing, companies are opting to insure their employees with High Deductible Health Plans. At Stride Strong, we have seen patients with deductibles as high as $10,000. To offset the out of pocket costs of meeting these deductibles, we encourage the use of FSA’s, HRA’s and HSA’s to pay for them. These are good sources of tax-sheltered money that are either contributed by your employer, or taken automatically from your paycheck. The money in these accounts can also be used to cover medical expenses other than medical bills – contact lens, prescription costs, etc. To determine the difference between FSA’s, HRA’s and HSA’s, here is a good website that compares them. To find out more how to take advantage of these accounts, ask your HR manager for more information.

By Alice Holland, DPT.
Alice’s Google + page.

Ana Lucia Pinheiro
Ana Lucia Pinheiro
02:18 20 Oct 17
This place is amazing. I am so happy I found Stride Strong PT. Alice pays attention to all of the details, she watches every single move I make, my posture, and the way I move through every exercise. She is very knowledgeable, she was able to pin-point the problems in my back and she has a plan to help me become stronger where I need. The place is brand new, huge, and has nice exercise machines. I tried a few physical therapists in the area, and Alice is TOP, second to none, and I feel super lucky to have found her. Highly recommended!!
Prashant Gupta
Prashant Gupta
01:00 02 Oct 17
Dr. Alice at Stride Strong is one of the best PTs I have come across. Her attention to detail and assessment of the root cause of injury is very good. She is excellent in evaluating pain patterns and giving a training schedule for a rehab & injury prevention, she is extremely knowledgeable. I would strongly recommend Stride Strong to anyone looking for PT. It is easily the best PT clinics in Hillsboro area.
steven zollin
steven zollin
20:57 14 Sep 17
Highly recommend Stride Strong Physical Therapy , Alice showed me proper form to assist in recovery with my shoulder and is very knowledgeable.
Lindsay Nied
Lindsay Nied
23:33 18 Dec 17
I recently had a massage from Joel at the Hillsboro location. He was able to work on an ongoing issue I have been experiencing with my back after a sports injury, and I left feeling so much better. The whole facility looked incredible, and everyone I met was friendly and welcoming. I would highly recommend Stride Strong for massage and physical therapy.
JoAnn Hatch
JoAnn Hatch
08:20 08 Nov 17
Dr. Sydney is by far the absolute best physical therapist I've worked with ever! Her expertise in designing highly effective and efficient exercise plans is beyond compare. I feel so much better as my strength and function increases. She comes up with the most brilliant and fun ideas to motivate. To my delight she even offered to come to my home in Vancouver and work with me on my own equipment including a Stott Pilates Reformer. Talk about going above and beyond! Couldn't be more grateful I found her!!!
Clare Perry
Clare Perry
21:58 23 Oct 17
A full hour of a dedicated PT professional's time without aides or techs? That's just one of the things that sets this clinic apart from others. Competent, professional, and amiable, Dr. Alice Holland and her team are the best in the area. While I generally see them at the Cedar Mill Clinic on Cornell, situational constraints took me to their new Hillsboro clinic today near Intel Jones Farm. Beautifully furnished, spacious with easy parking and access. May you continue to grow and thrive, Stride Strong!
See All Reviews

© Copyright 2017 STRIDE STRONG