Understanding Your Insurance Options

For many of us this time of the year, you are starting to hear “it is open enrollment period”. But what does that mean and how does it impact you?

Open enrollment is a period of time when you are able to sign up for health insurance. Whether you have health insurance through your employer, enroll through the Affordable Care Act health insurance exchanges, or on Medicare, open enrollment will be the start for signing up for healthcare coverage.

It’s important to note that not all health insurance plans have the same open enrollment period, it depends on which healthcare plan you choose.

  • Affordable Care Act health insurance exchanges or the “Marketplace” – open enrollment runs from November 1, 2016 to January 31, 2017 to sign up for 2017 health insurance. For more information visit healthcare.gov.
  • Medicare – open enrollment began October 15, 2016 and is open until December 7, 2016. For more information visit medicare.gov
  • Health Insurance through an employer – this is set by your employer and can happen any time throughout the year. It is best to check with your human resources department regarding open enrollment periods. Many have open enrollment in the fall with new health coverage beginning in January of the following year.

There are also healthcare plans that do not have open enrollment periods, and if you qualify you can enroll at any time. Those plans are:

  • Medicaid – state-based health insurance program that lets you enroll at any time, if you qualify.
  • CHIP – Children’s Health Insurance Program led by the U.S. government that lets you enroll at any time, if you qualify.


Why is Health Insurance Important?

Getting hurt or sick is not something people want to happen, but unfortunately these unforeseen circumstances happen and having health insurance can help individuals and families cover high medical expenses.

It’s important to consider your health insurance options, as in 2014 it became the law for those who can afford health insurance to enroll otherwise you would have to pay a penalty. Healthcare.gov stated, “In 2016 the fine for failing to have health insurance is $695 per person in the household, $347.50 per child, or 2.5% of your total household income, whichever is greater.”

In addition to this rule, there are many benefits to having health insurance:

  • With the Affordable Care Act, or Obamacare, in effect, individuals who need health insurance no longer have to worry about healthcare plans paying a limit on medical expenses. For example, someone with ongoing procedures could reach millions of dollars in hospital bills. Once you reach your share of payment, maximum-out-of-pocket, health care plans will help cover the remaining cost with no maximum limit.
  • There is an equality rule under the Affordable Care Act where health insurance companies cannot discriminate/cancel individual health plans because of critical or chronic health conditions.
  • If you have a pre-existing condition, you will not be denied health care coverage. There are health insurance plans out there for everyone.
  • Under the Affordable Care Act, preventative services, such as certain screenings, vaccines, and checkups, are covered for free. This means you have access to preventative services at no cost, without having to meet your deductible.
  • For those that make an income between 100%-400% of the Federal Poverty Level, between $11,770 - $47,080 depending on the state according to healthcare.gov, there is cost assistance available to help lower your monthly health insurance expenses. This is called a tax credit or tax subsidy.

Questions about Health Insurance

Now you may be thinking, “Once I have health insurance how do I use it, or what do all these terms mean?” Both are great questions that many of us ask.

Navigating the health care system itself can be confusing and lead to these frustrating questions. According to the National Assessment of Adult Literacy, only 12% of adults in the United States are at a proficient level in health literacy obtaining, processing, and understanding basic information and services needed to make appropriate decisions regarding your health, so it’s no wonder why these questions arise.   

At Divine Savior Healthcare we are fortunate to have a variety of patient services that help answer your questions like this and take a pro-active approach to your healthcare needs.


Help with Your Coverage at Divine Savior Healthcare

On a daily basis, Linda Bannen, Concierge and Patient Advocate at Divine Savior Healthcare assists patients with questions about their health care plans and how it covers medical services received at Divine Savior. If you have questions, such as:

  • Does Divine Savior accept my insurance?
  • I am not sure what preventative services are covered with my insurance, and where do I go to get these services?
  • Why does my billing statement say I owe a co-pay? I thought my insurance covered at 100%?
  • What is an EOB?

These are all questions Linda can help with and can be reached at 608-745-6239.

If you have specific insurance questions related to higher priced medical needs, such as surgery, high- tech radiology, rehab services, referrals to other facilities, medications, and every day office procedures, Prior Authorization Specialists at Divine Savior Healthcare are available to help patients check their health coverage and understand options as they make these important healthcare decisions.

What is a prior authorization? Many health insurance companies require prior authorization to be completed before certain medical costs, such as the services listed above, are covered by your health care plan. Every day these specialists are working with insurance companies, finding the best coverage solution for you.  

If you’re a patient at any one of Divine Savior’s clinics or rehab services and need assistance with a confirming prior authorization for a medical service, ask to speak with one of our Prior Authorization Specialists. 


Health Insurance Terms to Remember

Premium: The monthly payment you make to the insurance company for your health care policy.

Out-of-Pocket Cost: The amount you must pay during a year for your health care in addition to your premium NOT included in your monthly premium. This includes any deductible, co-pay, co-insurance, or extra costs for services.

Deductible: The amount you need to pay before the insurance company will start to pay its part.

Copayment: One of the ways you share in your medical costs fixed amount. You pay a flat fee for certain medical expenses e.g., $10 for every visit to the doctor, while your insurance company pays the rest.

Co-insurance: The amount you pay to share the cost of covered services after your deductible has been paid. The co-insurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.

Explanation of Benefits: The health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the company paid and what portion of the costs you are responsible for.

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