preventive care

Posts Tagged: preventive care


5 Ways to Better Manage a High Deductible

So you’ve got a health plan with a (gulp) high deductible. That’s pretty common these days, so you’re not alone. In fact, a good chunk of the plans sold on the insurance exchanges are high deductible health plans (HDHPs).

High deductible plans are great because they cost less when it comes to the monthly premium. But you need to be prepared for when, or if, the bills start coming in.

Here are five things you can do now to make managing your deductible easier.

1)  Save save save

One of the worst things you can do if you have a HDHP is to go without savings sufficient to cover your deductible. This is why all HDHPs come paired with a Health Savings Account option. HSAs let you save money tax-free. If you’re going to save for medical expenses anyway, why not get a break on taxes too? If your health plan is through your employer, they may already be making contributions to your HSA. In addition, you might also consider putting in your  own monthly contribution, as most employers only contribute enough to fund the full deductible over the course of an entire year. If you want the savings to build up faster, you’ll need to kick in some funds yourself.

2) Know what’s excluded

Because of the Affordable Care Act, all health plans must provide preventive care free of cost. That means these services won’t count towards your deductible. It’s also common for plans to exclude certain co-pays or have a separate deductible for prescription drugs or for out-of-network providers. What you don’t want is to be in a situation where you thought you were fulfilling your deductible when you uhh, really weren’t.

3) Understand family deductibles

Do you have your spouse or children on your health plan? Each member of the family may have a separate deductible. To make things more confusing, there are no standard rules for how plans calculate these. Each individual member may just need to meet their deductible separately. Or it may be the case that one member of the family must meet the entire family deductible for coverage for everyone to start. Check with your health plan if you’re unsure.

4) Know the plan year

Most plans use the calendar year (January to January) for resetting deductibles. However some use a fiscal or academic year. Also keep in mind that the deductible year could be different from the rollover period for FSAs or HRAs for your plan.

5) Reevaluate if needed

HDHPs tend to work best for people who either don’t use a lot of health care or who, if they are sick, have a lot saved up. If you anticipate a lot of expenses year after year, you may find a lower deductible plan works better. Don’t be afraid to switch plans at your next opportunity if this feels like you–remember, you won’t lose any money left in your HSA if you choose to do this. HSA funds belong to you once they are in your account, regardless of if you change plans or employers.



What does “Deductible Waived” on Co-Pays Mean (And Is It a Good Thing)?

When you see what your health plan’s co-pays are, it’s easy to tell how much you’d pay for a doctor’s visit, lab test, or x-ray. But what does it mean when the “Deductible is Waived” for the co-pay? And will this cost you more or less in the end?

Normally, you are responsible for paying your full deductible before your insurance pays anything towards your health care. However, some plans will waive the deductible for certain services, usually office visits or emergency care if you’re admitted to a hospital.

Let’s say your co-pay for a doctor’s visit is $25 and your deductible is $1,500. If the doctor charges $200 for a visit, you would normally pay the $200 yourself and it would be applied to your deductible. If the co-pay is waived, you’ll just pay $25.

Sounds like a good deal right?

Maybe, maybe not. Waived co-pays can be a great deal if you are pretty healthy and do not expect to meet your deductible. They’ll allow you to skip over paying the full charge and only be responsible for the co-pay. They can also save you a lot of money if you are ever admitted to a hospital from the emergency department.

But if you would meet your deductible anyway, this feature doesn’t really save you money in the end. It might actually drag out how long it would take you to meet your deductible, just shifting the out-of-pocket cost to other services. Or even worse, some plans will not apply that $25 co-pay you just paid to your deductible, so you won’t get credit for the money you just spent.

And keep in mind that many preventive care benefits are 100% covered anyway, regardless of whether you met your deductible.

So your best bet? Enjoy the waiver benefit if you have it. But be wary of paying a higher premium for the feature if you use a lot of health services–it might not be worth the cost. And always check on exactly what costs are applied to your deductible if you expect to meet it!


How to Start a New Health Plan Off on the Right Foot

Welcome to a new year, with new health benefits. You just chose a new health plan and now it’s in full effect. But most people don’t have a full understanding of how their benefits work. This means that many of them end up losing money in their spending accounts, paying more for care, or getting claims denied.

Follow these tips to make sure you start off 2013 right.

Plan for your Deductible
Guess what–deductibles have gone through the roof over the years, so that often means more cash out of your pocket. If you are one of the 65% of people who have a high deductible health plan, it’s especially important for you to plan your spending. High deductible health plans (HDHPs) come paired with Health Savings Accounts (HSAs), or accounts where you can save money just for medical expenses free from taxes. To be best prepared, you should plan to save at least the amount of your deductible in your HSA as soon as possible.

Network It
Most health plans have some restrictions on what providers you can see or they cover much more on visits to in-network providers. Find out the type of plan you have and whether you have a provider network. HMO plans are the most restrictive–don’t even think about going to a non-network provider unless you want to pay the full cost. PPOs have some more flexibility, but services in-network will be less expensive. POS plans give you more freedom, but often involve more paperwork for out-of-network visits. And finally, FFS plans allow you go to any provider you want, but few companies offer this option anymore.

Get Spent
Did you sign up for an FSA or HRA? Don’t forget about the money in your account. These funds disappear if you do not spend it by the end of the year. Do some planning now by finding what eligible expenses you expect this year so that when they come up, you’ll know to pay with your FSA or HRA, insteading of other funds. If you have an HSA, the same “Use it or lose it” rule does not apply. Your savings will roll into the next year.

Practice Prevention
All health plans must cover a list of dozens of preventive care services, all free of cost. Get your money’s worth by checking out the list and asking your physician what they recommend. Even if you have a high deductible plan and you have not met your deductible, you can still get these services completely covered, as long as you don’t have a pre-existing condition that already required one of these tests or screenings. Learn more about preventive care here.

Have a Non-Emergency Plan

What do you do on the weekend or in the middle of the night when you’re not sure if a medical condition is serious enough for the ER or can wait for a doctor’s appointment?  Most health plans have a variety of options for these uncertain situations such as nurse advice lines or extended-hours urgent care. Know your options so that if you’re caught in the situation, you can choose to avoid an expensive ER visit. Of course, always go to the ER if you are having a life-threatening emergency.


65 Free Preventive Care Benefits to Take Advantage Of

It’s been said that nothing is free – even with health coverage.

But if you’ve already paid your premiums, now is the time to take advantage of all the 100% covered benefits.

Health plans are required to completely cover 16 free preventive services for adults, 22 for women, and 27 for children. That means you won’t pay any co-pays, co-insurance, or deductibles on any of these 65 services.

Here’s how you can make the most of those free benefits.

Get your basics done.

Aim to get an all-around profile of your health with screenings or wellness counseling.

  • Breast & colon cancer screenings
  • Diabetes, blood pressure, cholesterol, STD, HPV, & depression screenings
  • Vaccines for flu, pneumonia, measles, polio, meningitis
  • Annual check-ups for women
  • Counseling to quit smoking, lose weight, stop drinking, or on HIV and STDs, domestic violence, or breastfeeding.

Here is a complete list of services.

Tell your doctor

The next time you see your doctor, mention that you want to take advantage of your preventive care benefits.

If your doctor has record of you asking about them, they’ll not only be able to start you off, but they’ll see it in their notes whenever you come in and follow-up with you.

Basically, put it on the record: You’ll be more likely to get things done when someone else is part of the plan.

Know the limits

“Free” doesn’t necessarily mean, “always free.” The key is the word “preventive.”

If you’ve had a past medical history that now requires care that would normally be free, it doesn’t count.

For example, if you had a breast cyst, a mammogram would no longer be considered a preventive care benefit.

The same thing happens if the service is aimed at diagnosing a specific illness: if your doctor orders a colonoscopy because you’re having stabbing abdominal pain, the preventive care benefit wouldn’t apply.

Check your bills

For your health plan to treat a claim as a free preventive benefit, it needs to be coded with the right medical billing codes.

For example, a mammogram for a breast cancer patient will have a different code than a mammogram for a perfectly healthy woman.

Doctors and insurance companies make mistakes, so you should review your bills to make sure you weren’t charged. If you’re billed for a service you think should be free, call your health plan or ask your doctor about it.


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Getting The Most Out Of Your Health Insurance Plan

Health plans certainly come with no shortage of rules. And you’ll want to be sure to follow them in order to get the most out of your coverage.

1) Find the freebies.

If you joined your health plan on or after September 23, 2010, you can get many preventive care services free of cost. Yes, that means no co-pay or coinsurance, even if you have not met your deductible.  This includes services such as cholesterol and diabetes screenings, women’s exams, osteoporosis tests, STI (sexually transmitted infection) counseling, immunizations, smoking cessation evaluations, depression screening, many screenings for children, and more. For a complete list, visit

Even if you were enrolled in your health plan prior to September 23, 2010, the plan may still offer the same preventive care benefits, so it is worth investigating.  Check out the “Your Plan” tab in your Simplee dashboard to see details of what your plan offers.

In addition, many plans also offer benefits such as discounts on gym memberships, weight-loss programs, or vitamins. After all, most everything that keeps you healthy and away from the doctor will save both you and your plan money in the long run.

2) Use your network.

If you have an HMO or PPO, your plan contracts with a network of providers. You are probably already aware that seeing physicians within the network will save you money. But plans may also contract with network hospitals, labs for blood tests, medical supply companies, home health providers, or imaging centers. Checking to see if these providers are a part of your plan before going to them for services can also save you money.

And after you have received the service, make sure to check your claim over on Simplee to make sure that you were properly charged.

3) Plan around the deductible.

Many plans have an annual deductible. For example, if your deductible is $500, you must pay $500 out of pocket for your medical care before the plan starts paying for any covered services. If you reach your deductible during the year, it may save you money to take care of any other health needs you have that year, before your deductible renews. Or if you know you will be incurring a number of health expenses that will put you over your deductible, you may want to plan them to fall within the same deductible year so you do not end up needing to meet the deductible twice. If for example you have a calendar-year deductible and you are planning a series of procedures, you may want to avoid scheduling the first in December, in case they lapse into January.

Also keep in mind that some plans may have a separate deductible for in-network providers than for out-of-network providers—you might be starting from zero if you go out of network, even if you’ve already met the in-network deductible.

4) Ask about your drugs.

Every health plan has a formulary, or list of drugs that are covered. Formularies often divide drugs into tiers, or different levels of coverage: For example, a tier 1 drug may have a $35 co-pay while a tier 2 drug has a $10 co-pay. Doctors often have no way of knowing the level of coverage for a drug on your plan when they are prescribing it. Before filling a prescription, you can check the level of coverage with your plan. If it falls on a more expensive tier (or is not covered at all), ask your doctor if there is a similar or equivalent drug you can take which might have better coverage.

5) Understand utilization management.

Many plans now use a process called “utilization management,” where certain procedures must have prior-approval from the plan before they are covered. You should find out if your plan has such requirements. If so, always make sure you have gone through all the steps to get a service authorized before you receive it. Usually, it is up to your doctor’s office to contact your insurance company to start the utilization review, but it is ultimately your responsibility to make sure it gets done.

Above all, the best way to get the most out of your plan is to understand the rules. Every health plan is different. Sometimes, the rules can even be different for two people with the same plan, depending on when each of them joined. You can view all the details about your specific plan when you log in to your Simplee account. If you have any additional questions, call the plan—it’s best to know so you don’t get that surprise bill later on.


The Patient Protection and Affordable Care Act and What it Means for Consumers

By now you have probably already heard more than you wish to digest about the Patient Protection and Affordable Care Act (ACA). Regardless of whether or not you are a supporter or an opponent of the new law, implementation of provisions that will affect you and your family is already underway, and it is important for consumers, like you and me, to know how and when we will be affected.

The ACA means so many different things for providers, the insurance industry and regulators, but what does it mean for you and me, the consumers? I will spare you the nitty gritty details of every single provision in the health care law, and perhaps we can start with the top ten provisions that I think consumers should be aware of.

1. Coverage cannot be denied to individuals with pre-existing conditions. I have heard horror stories from consumers who were denied health coverage because they were diagnosed with acid reflux disease or had freckles or even because they were pregnant. Under the ACA, insurance companies will no longer be able to refuse coverage to individuals with pre-existing medical conditions. Although this provision doesn’t kick in for adults older than 19 until 2014, insurance companies are prohibited from limiting or denying coverage to children with pre-existing conditions as of 2010. In the meantime, the law establishes funding for a temporary subsidized high-risk pool that provides coverage for uninsured adults with pre-existing conditions until health insurance exchanges are created in 2014.

 2. Free preventive care. We all love freebies, and under the ACA, those of us with new policies will be receiving a major one. Effective as of 2010, new health policies from private plans must offer preventive care such as mammograms, colonoscopies, vaccinations and preventive screenings for free. So that means no co-pays, no deductibles and no coinsurance for these services.

3. Coverage cannot be rescinded. In addition to hearing countless horror stories about consumers being denied coverage due to pre-existing conditions, I have also heard stories that are just as horrific about consumers being dropped from their coverage once they become sick. Effective already is the provision that prohibits insurance companies from retroactively canceling consumers’ insurance coverage unless they can provide proof that the consumer intentionally committed an act of fraud. Of course, determining intent can be very subjective, especially if the insurance company is making that decision. Fortunately, for consumers, the ACA also creates new review boards that decide objectively what constitutes fraud.

4. Restrictions on imposing limits on insurance coverage. Some of us have insurance plans that include something like a $100,000 limit on coverage. That sounds great, right? Wrong! Anyone who has been diagnosed with a serious condition or who has experienced a medical emergency knows that $100,000 in health expenses can disappear very quickly, and once you have reached that limit, you are on your own and out of luck. Currently, under the new law, insurance companies are restricted from imposing lifetime dollar limits on coverage, and by 2014, they will be restricted from imposing annual limits on coverage.

5. Consumers will have more options to appeal coverage decisions. Many consumers have had to deal with the headache of receiving a letter stating that their insurance provider has denied their claims and in addition, they will not be able to appeal the decision. The new law ensures that consumers have access to an effective internal and external appeals process. In other words, consumers have the right to demand that their insurance provider reconsider a decision to deny payment for a medical procedure. Additionally, consumers can also make an external appeal to an independent reviewer.

5. Medicare beneficiaries can say goodbye to the “donut hole.” If you are a senior or if you have older family members or friends, then you are probably familiar with the Medicare “donut hole.” The “donut hole” represents the gap in prescription drug coverage that Medicare Part D beneficiaries have to account for. To clarify,  once a Medicare beneficiary reaches around $2,250, in prescription drug benefits, then he or she will be responsible for paying the next $2,250 toward prescription drugs before Medicare coverage kicks back in. For some seniors who are already on fixed incomes, this means, cutting pills in half or deciding not to take medications altogether. Beginning in 2010, Medicare beneficiaries who hit the “donut hole” will receive a $250 rebate. Each year, that rebate will get larger until the “donut hole” is closed completely by 2020.

6. Consumers will be provided with tools to understand their health plans. Navigating insurance plans can be incredibly confusing and discouraging, especially when insurance companies fail to disclose information that can be important and helpful for consumers. When consumers do not understand what their plans include or what they are purchasing, they can be vulnerable to falling into medical debt. The ACA provides funding to states to establish or expand offices of health insurance consumer assistance in order to help individuals file complaints and appeals and understand their benefit packages. In addition, insurance companies will be required to publicly post consumer health insurance information.  

7. Insurance companies will be prohibited from issuing unreasonable rate hikes. In 2010, insurance company rate hikes caught the media’s attention. Consumers were receiving notices informing them that their rates would be increased by up to 33% and that insurance companies have the right to issue rate increases more than once a year. Consumers were outraged, especially when insurance companies were unable to justify the rate hikes. The ACA creates a grant program to support states in requiring health insurance companies to submit justification for all requested premium increases.

8.  Young adults can stay on their parents’ plan until age 26. Although some young adults are fortunate enough to land a job that offers them good health benefits right out of high school or college, the reality is that the majority of young adults are not this fortunate and have difficulty purchasing expensive private insurance plans on their own. Under the ACA, parents have to option to add or keep their children on their health policy until they turn 26, even if their child is not claimed as a dependent, lives in another state or has a full-time job.

9. No more penalties for using out-of-network emergency rooms. When you are suffering from a medical emergency, the last thing you want to be doing is worrying about whether or not your health plan will cover the emergency room services you are receiving. New health plans will be prohibited from requiring consumers to get prior authorization before seeking emergency room services from a provider or hospital outside a plan’s network. In addition, they will also be prohibited from requiring higher co-pays and co-insurance for these services.

10. The individual mandate. Most consumers are aware that by 2014, they will be required to have health insurance coverage. Without the individual mandate, the health reform law would not have been as viable.  Younger, healthier individuals might opt out of coverage and the insurance pools would be disproportionately utilized by people who are older and sicker. As a result, premiums would be raised for everyone. Furthermore, because insurance companies are no longer allowed to deny coverage due to pre-existing conditions, the individuals who initially opted out of coverage can opt back in once they get sick. The mandate ensures shared responsibility among consumers. The ACA also includes subsidies for purchasing insurance for consumers who qualify and exemptions for reasons such as financial hardship, religious objection and immigrant status.

What we covered here is just the tip of the iceberg when it comes to the ACA, but hopefully this will serve as a starting point in understanding how you, the consumer, could be impacted by health reform. For more details about health reform and what it means for you, a good site to start with is