October 15, 2018
When you aren’t feeling well, all you want to do is feel better, not worry about trying to navigate the complexities of medical billing. But as the old saying goes – luck favors the prepared. It’s important to understand your health insurance plan and potential healthcare costs before you or anyone in your family actually need care, so when the time comes, you have answers to all of your questions and can focus on the most important thing – feeling better.
Let’s Start With Some Health Insurance 101
So what is health insurance and how does it work? Health insurance is a type of insurance that exists to help you pay for medical expenses and prescriptions. You can receive health insurance through your employer, a federal program like Medicare or Medicaid, or purchase private health insurance plans through the Health Insurance Marketplace.
A quick reminder – if you have insurance through your employer, typically there are specific times that you can “sign up” for coverage: when you’re hired, after a qualifying life event that makes you eligible for a special enrollment period (for example, marriage, divorce, or a new baby), or during open enrollment. Open enrollment is a time period designated by your employer to make updates or changes to your health insurance plan. Open enrollment typically occurs between October to December each year.
If you have insurance, you’ll likely pay a premium each month. Think of this almost like a gym membership. You pay a certain amount each month to have health insurance coverage, just like you would pay a certain amount each month to belong to a gym. If you subscribe to health insurance through your employer, your premium is likely automatically deducted from your regular pay check, so no extra work is needed on your end. Different health insurance plans have different premium amounts − simply put, high premiums or low premiums. Generally speaking, the more you pay per month in premiums, the lower your deductible will be.
Wait…deductible? What is a deductible? A deductible is the amount of money you have to pay every year toward medical bills before your insurance company will start covering costs. This cost is in addition to premiums. Today, many people have what is known as a high deductible plan. These plans are aptly named, meaning you pay a lower premium each month, aka your monthly insurance payment, but you will be responsible for meeting (or paying) a much higher total amount before your insurance company starts footing the bill.
One question that seems to pop up a lot is whether or not premium payments count toward your deductible. The short answer is no. Premiums are just monthly payments that keep your health insurance coverage active (remember that gym membership), whereas deductible payments count toward your actual medical expenses or claims.
And here’s one more tidbit about deductibles; while premium payments don’t count toward your deductible, depending on the specifics of your insurance plan, your deductible, copayments, and coinsurance may count toward your out-of-pocket maximum. Wow! That sentence had a lot of insurance terms in it, but don’t worry, we’ll walk through them one by one.
Co-insurance and Co-pays
Co-insurance and co-pays are easiest to think about together. While they are different, they are both terms for cost sharing between you (the policy holder) and the insurance company, and most health plans are designed to have one or the other.
Let’s start with co-pays. Co-pays are an amount predetermined by your health plan that you pay upfront at the time of service. The exact co-pay amount is determined by the specifics of the insurance plan you choose and can vary based on the type of healthcare provider you are seeing. For example, a co-pay for a trip to the emergency room might be $100, while a co-pay for a trip to an urgent care center might be $25. This is yet another reason to do a bit of pre-homework to familiarize yourself with your health plan and the various co-pay amounts for primary care physicians, urgent care centers, specialists, and emergency rooms before you enroll in an insurance plan.
Co-insurance is a different type of cost sharing. After you’ve met your deductible, some health plans are structured to have you pay a percentage of the total bill (commonly 20 percent), while the insurance company covers the rest (in this example 80 percent) until you reach your out-of-pocket maximum.
Luckily, this terms means exactly what you think it does. This is the absolute maximum amount of money that you would pay out of your own pocket for medical expenses in a year – and remember, for some plans, your deductible, co-insurance, and co-pay payments may count toward this total. After you hit this amount, your insurance company typically covers the rest.
In Network and Out of Network
And last but not least, if a provider or healthcare facility is considered out of network, it means that provider does not have a contract with your insurance company. Most of the time, you’re still able to receive care from an out of network provider, it will just likely be a more expensive visit than if you chose to see an in network provider. If you ever change to a new health insurance provider, it’s always a good idea to check and make sure your primary care physician (PCP) and other healthcare providers are in network with your new insurance before making the move.
MedExpress Pro Tip: Not sure if MedExpress accepts your insurance? The good news is that we likely do, but there’s an easy way to check. Our website lists the insurance plans accepted by state and also allows you to search other states.
So What Are Those Terms Again?
Here's a cheat sheet to help you keep all those health insurance terms straight:
- Premium - The amount you pay each month to receive healthcare insurance.
- Deductible - The amount of money you have to pay every year toward medical bills before your insurance company will start covering costs.
- Co-pay - A predetermined amount that you pay upfront at the time of service.
- Co-insurance - A percentage of the bill you are responsible for paying after you’ve met your deductible.
- Out of Pocket Maximum - Typically, the maximum amount of money that you could pay out of pocket for medical expenses in a year.
- In Network/Out of Network - A healthcare provider or facility that has a contract (in network) or does not have a contract (out of network) with your insurance company. In network visits are typically less expensive.
Know Before You Go…
Today, you have more options than ever when it comes to your healthcare – from primary care offices to the emergency room and urgent care centers. But the increase in options has also led to patient confusion about where to go, with research showing that up to 90% of ER visits could be treated at a place like MedExpress.1 While getting the most appropriate level of care is always the most important thing (please remember, life-threatening conditions, such as trauma and chest pains, and medical emergencies should always be treated in an ER), for everyday illnesses and injuries that aren’t life-threatening but still require timely care (hello, UTIs!), urgent care centers can be a convenient and affordable option. Understanding the differences between the various healthcare options can ultimately help you save time and money while still getting the level of care you need. And in case you missed it, in some states, some insurance companies are taking new actions to prevent emergency room overuse by denying to pay expenses for out-of-network ER visits for non-emergent issues.
But What If I Don’t have Insurance?
If you don’t have insurance, you can absolutely still visit MedExpress. MedExpress has a program called Prompt-Pay, which offers affordable pricing for those without insurance or for those who wish to pay in full at the time of service. If you’d like to use this program, you just have to let our front office team know when you walk in to a MedExpress.
So Tell Me, How Much Does an Urgent Care Visit Cost?
The tricky part here is that it truly varies. The cost of your urgent care visit is determined by the following:
- The specifics of your insurance plan
- The services and treatment you receive
Insurance companies determine the cost of a visit to an urgent care center in advance when they are developing your benefits plan with your employer. Luckily, most insurance companies cover trips to urgent care, but don’t forget about those co-pays and deductibles. You can always call your insurance company (before hopping in the car to head to the doctor) to make sure you know the ins and outs of your plan.
In the end, a little bit of homework can go a long way in understanding your insurance plan and potential costs – ultimately helping you to make the most informed decision about where to go when your family needs care.
1 National Hospital Ambulatory Medical Care Survey: National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. Published 2011. Accessed Aug. 31, 2018.