Question 1

What is a premium?

Accepted Answer

Your premium is the amount you pay every month just to have health insurance, whether or not you use it. Think of it like a subscription. Important: your monthly premiums do not count toward your deductible or your out-of-pocket maximum.

Question 2

What is a deductible?

Accepted Answer

Your deductible is the amount you pay for covered care each year before your insurance starts sharing the cost. For example, with a $1,500 deductible, you generally pay the first $1,500 yourself, and then your plan begins to pay its share. Preventive visits are often covered even before you meet your deductible.

Question 3

What is a copay (copayment)?

Accepted Answer

A copay is a fixed dollar amount you pay for a specific service, like $30 for an office visit or $15 for a prescription. You usually pay it at the time of the visit. Copays can be different for primary care, specialists, labs, and medications.

Question 4

What is coinsurance?

Accepted Answer

Coinsurance is your share of a cost written as a percentage instead of a flat fee. If your plan pays 80 percent after your deductible, your coinsurance is the other 20 percent. So on a $200 covered service, you would owe $40.

Question 5

What is an out-of-pocket maximum?

Accepted Answer

This is the most you will have to pay for covered care in a plan year. Your deductible, copays, and coinsurance all count toward it. Once you reach it, your plan pays 100 percent of covered services for the rest of the year. (Your monthly premiums do not count toward this limit.)

Question 6

What do in-network and out-of-network mean?

Accepted Answer

In-network providers have a contract with your insurance company and agreed-upon rates, so you pay less. Out-of-network providers do not have that contract. In that case you pay for the visit up front, and you may then submit the claim to your insurance yourself for possible reimbursement — but only if your policy includes out-of-network benefits. Many plans do not. It is always worth confirming that a provider is in your plan's network before you are seen.

Question 7

Why is the amount on my bill different from what the doctor charges?

Accepted Answer

Insurance companies negotiate a lower rate for each service, called the allowed amount. Even if the office charge is $200, if your plan's allowed amount (or allowable) is $120, that lower number is what counts. You pay your share of the allowed amount (through your deductible, copay, or coinsurance), not the full sticker price.

Question 8

What is prior authorization?

Accepted Answer

Prior authorization (sometimes called pre-authorization or pre-cert) is approval from your insurance company before you get certain tests, procedures, or medications. Without it, your plan may not pay. Our team handles these requests for you when they are needed, though they can take a few days, so a little advance notice helps.

Question 9

Is an Explanation of Benefits (EOB) a bill?

Accepted Answer

No, and this trips up almost everyone. An EOB is a summary your insurance company sends after a visit showing what was charged, what they paid, and what you may owe. It usually says right on it, this is not a bill. The actual bill comes separately from the provider. It is smart to compare the two.

Question 10

What are preventive services, and why are they often free?

Accepted Answer

Preventive care includes things like your annual well-woman exam, many screenings, and certain vaccines. Under most plans, these are covered at no cost to you (no copay or deductible) when you see an in-network provider, because catching problems early keeps you healthier and lowers costs. If additional testing or treatment is added during a preventive visit, that part may be billed normally.

Question 11

Why did I get a bill after my insurance already covered my visit?

Accepted Answer

Covered does not always mean free. Your plan may have paid its share while leaving you responsible for your deductible, copay, or coinsurance. You might also owe for a service that was not fully covered. If a bill ever surprises you, call us, and we are happy to walk through it with you.

Question 12

What are an HSA and an FSA?

Accepted Answer

Both let you set aside pre-tax money to pay for medical costs like copays, deductibles, and prescriptions. An HSA (Health Savings Account) pairs with a high-deductible plan, and the money rolls over year to year. An FSA (Flexible Spending Account) is offered through an employer and usually must be used within the plan year. You can use either to pay for care with us.

Question 13

How do I find out what my plan covers here?

Accepted Answer

The fastest way is to call the member services number on the back of your insurance card and ask whether G. DeAn Strobel, MD, PA is in-network and what your costs would be. Most plans also have an online member portal where you can look up your deductible, copays and covered services yourself, if you would rather not call. Your benefits are specific to your policy, so your insurance company is the most reliable source for what you will owe.

Question 14

Why can't my problem be addressed during my well-woman visit?

Accepted Answer

A well-woman exam is preventive care, which most plans cover at 100%. A problem visit — a new symptom such as itching, discharge, pelvic pain or a breast lump — is billed differently and goes toward your deductible or a copay. More insurers have begun declining to pay the preventive visit in full when both are done on the same day, which can leave you responsible for both. We cannot tell in advance which plans will do that. So rather than risk it, we take care of the problem at that visit and reschedule your well-woman exam for another day.

UNDERSTANDING YOUR HEALTH INSURANCE COVERAGE

BASIC INSURANCE TERMS

CO-PAYMENTS

DEDUCTIBLES

CO-INSURANCE

WELLNESS VISIT

Frequently asked questions