What does my plan cover?
Every plan has different coverage standards and requirements. Your insurance company sent you a document when you signed up for your health plan that listed all covered services, all patient responsibility and a breakdown of your financial responsibility for your coinsurance/copay/deductible etc. It is also available online in your patient portal. It is always best practice to call your member services/customer service number on the back of your card to find out what is a covered benefit for your particular plan and what services you may have to pay out of pocket for. It is also your responsibility to ensure Planned Parenthood is in network with your plan.
Why do I have to bring my card and ID with me to each visit?
We are unable to bill your insurance if we don’t have the important information off your card which includes your name, ID number, group number, address to submit claims, payer ID and more. Additionally our claims are transmitted electronically so we need a copy of your card to be able to scan into our computer systems to import into the claim fields. We must have your ID in order to verify that you are the same person whose name is on the card.
What is an insurance premium?
This is the amount you pay monthly to your health insurance company to have insurance coverage.
What is my copay?
A copay is the amount of money you pay to a doctor’s office when you have a non-preventative visit. This amount is determined by your health insurance company, not your doctor’s office. Your doctor’s office is required to collect a copay from you if your visit indicates it is appropriate. There may be different levels and amounts of copays, including office visit copays, specialist, or hospital copays. They are listed on your card.
Why do I owe a copay for some of my visits and not for others?
Under the Affordable Care Act (ACA) health plans are required to make preventative services available to patients with no patient responsibility. Therefore for some of the visits we offer (well woman exams, immunizations, etc) we do not collect a copay. For other visits, your health plan requires that we collect a copay. Planned Parenthood does not get to decide if we collect a copay or not – we are required to follow health plan rules regarding the collection of copays.
What is a deductible?
A deductible is the amount of money you must pay for your health care services before your insurance company pays for any service/product. Preventative visits are not a part of the deductible and will be covered at 100% regardless of if you have met your deductible yet. This is an amount that you agreed to pay for your healthcare services when you signed up for your insurance plan.
What is coinsurance?
Coinsurance is the amount that you are responsible for after you have paid your deductible and your insurance plan begins to cover some of the cost of your healthcare visits. Most plans run on a 90/10 or 80/20 split. If you have a 90/10 split it means that out of the total amount due (after a copay is paid if required and contracted adjustments have been made), the plan will pay 90% and you will be responsible for 10% of the bill.
What is my plan year?
Your health insurance plan and rates are good for one year. Most health insurance plans begin at the beginning of the calendar year (but some do not!) which means that you are responsible for paying your deductible again when your plan turns over into a new plan year.
What does it mean when my plan documents say maximum out of pocket?
This is the total amount you will have to pay annually (not including your premiums) for healthcare in a given Plan Year. It includes your deductible and your coinsurance payment amounts – so it is an absolute maximum. This does reset with new Plan Years. After you reach your maximum out of pocket, your insurance will pick up 100% of all of your healthcare services.
What is an explanation of benefits (EOB)?
This is a piece of paper that may get mailed to you or is available on your patient portal on your health insurance plan’s secure website. It is usually generated for every healthcare visit you have and is a reference for you to understand what was covered and not covered by your plan. It will list what the insurance paid for, what went to in network or out of network deductibles (if you have these) and what you owe and why. The best person to answer questions about your EOB is your health insurance plan. Please call the number for patient inquiries on back of your card if you have questions about the EOB.