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Insurance FAQs By O&P Business Solutions 


 

“Specializing in Business, Compliance, Claims & Billing & Administrative Practices in Orthotics &Prosthetics

                   

 

 

 

Q:         WHAT DOES LIFETIME MAXIMUM MEAN?

 

A.         Most fee-for-service plans will pay only up to a maximum amount, such as $1 million, during your lifetime towards total medical expenses or for certain medical conditions. This is called a "LIFETIME MAXIMUM."

 

Q.         WHAT IS THE BIRTHDAY RULE FOR SPOUSE COVERAGE?

 

A.         If two spouses are covered by separate health plans, and both plans cover their dependents, the "BIRTHDAY RULE" takes effect. This means the plan of the parent who has the earlier birthday in the calendar year pays first. For example, the plan of a parent whose birthday is July 3 would pay for a child´s health care before the plan of the other parent born on July 4. However, if the first parent´s plan reaches its benefits maximum, the second plan can take effect. In the event of a divorce, a court usually determines which parent´s plan is a dependent´s primary coverage.

 

Q.         WHAT DOES FEE-FOR-SERVICE MEAN?

 

A.         The Fee-for-Service plan is also known as the traditional "INDEMNITY PLAN".  With a fee-for-service plan, you can go to any doctor or provider you want, and you don´t need a referral to see specialists. A fee for service plan will generally pay for most, but not all, of the health care costs for medical conditions covered by the policy and deemed "medically necessary."  Often your provider will have an established relationship with your insurer, and will bill the company directly for its share of the costs. In some cases, however, you will have to pay the full bill up front and then file a claim with your insurance company for reimbursement.

 

ADVANTAGES

Þ                   You may choose your own doctors and hospitals.

Þ                   You may visit any specialist without getting permission from a primary care physician.

 

DISADVANTAGES

Þ                  There's typically a deductible (anywhere from $500 to $1,500) before the insurance company starts paying claims, and then doctors are reimbursed about 80 percent of the bill while you pick up the remaining 20 percent.

Þ                  You might have to pay up front for medical services, and then submit the bill for reimbursement.

Þ                              FFS plans pay only for "reasonable and customary" medical expenses. If your doctor charges more than the average for your area, you will have to pay the difference.

 

Q.         WHAT IS AN HMO PLAN?

 

A.         HMO is a Health Managed Organization where your healthcare is “managed” by a primary care physician, usually a general practitioner. HMO plans are MORE RESTRICTIVE than other plans. HMO’s usually pay primary care physicians a set monthly fee - called aCAPITATION FEE - for each member, regardless of the amount of covered services performed.

    

Typically, you must receive a REFERRAL FROM YOUR PHYSICIAN BEFORE visiting a specialist outside the provider network. With rare exceptions, such as when you are away traveling, you are limited to seeking care completely within the network of providers, doctors, hospitals and labs with whom your HMO has negotiated a fee schedule. Since contracting discounts from a network of providers is one of the primary ways a HMO maintains cost effectiveness, the plan only works when you stay within the network. In addition to your premium, an HMO generally charges a co-payment (a way of sharing per visit costs between the consumer and the plan) of, for example, $10 or $20 for certain services or prescriptions. One of the unique features of an HMO is that they typically deliver care directly to patients. Patients visit an HMO’s medical facility to see the physicians. Most HMOs own their own hospitals and clinics and directly hire physicians who work only for them.

 

ADVANTAGES

Þ                  They offer their customers low co-payments, minimal paperwork, and coverage for many preventive-care and health-improvement programs.

 

DISADVANTAGES

Þ                  You MUST CHOOSE A PRIMARY CARE PHYSICIAN, also known as a PCP.

Þ                  HMOs require you to SEE ONLY NETWORK DOCTORS, or they won't pay.

Þ                  You MUST GET A REFERRAL FROM YOUR PCP TO SEE A SPECIALIST.

 

 

Q.         WHAT IS A POS - POINT OF SERVICE PLAN?

 

A.         Point of Service (POS) plans have similarities to both PPO and HMO plans. As with Preferred Provider (PPO) plans, you are directed toward a network of contracted doctors, hospitals and clinics for your healthcare, but you can pay a larger out-of-pocket fee to visit an out-of-network provider. In line with the managed care policies of an HMO, your healthcare is administered according to a healthcare professional. With a Point of Service plan your primary doctor oversees your medical care and refers you to contracted specialists when the need arises.

 

The upside to a Point of Service plan is the FREEDOM TO GO OUT ON YOUR OWN AND CHOSE YOUR OWN PROVIDERS, EVEN SPECIALISTS, OUTSIDE THE NETWORK. You are never limited to medical providers your primary care physician refers. However, be aware, the dollar amount the plan will pay decreases when you go outside the network. You will pay approximately $600 a year for the privilege of being allowed to self-refer to out-of-plan practitioners, and your out-of-pocket contribution will be greater. It is wise to consider if it is worth it to you, as a consumer, to pay a higher monthly payment for the freedom to access specialists, physicians, and clinics of your choice. If you are relatively healthy and do not have a special relationship to a specific physician, then you might consider a managed care program that will charge you less to exercise less freedom in choosing a healthcare provider.

 

ADVANTAGES

Þ                   Depending on your insurance company's rules, you may choose to visit a doctor outside the network and still receive coverage — but the amount covered will be substantially less than if you went to a physician within your network.

Þ                   These plans tend to offer more preventive care and well-being services, such as workshops on smoking cessation and discounts to health clubs.

 

DISADVANTAGES

Þ                  You must choose a PCP.

Þ                  While you may choose to see a physician outside the network, if you don't receive permission from your PCP, you're likely to wind up submitting the bills yourself and receiving only a nominal reimbursement — if any.

 

Q.         WHAT IS A PPO - PREFERRED PROVIDER ORGANIZATION?

 

A.         Preferred Provider Organization (PPO) generally offers the most choice of any type of managed care plan. PPO plans are similar in concept to POS plans, except that they´re administered by insurance companies. You´re FREE TO RECEIVE HEALTH CARE FROM ANY PROVIDER, but you pay lower deductibles and less in coinsurance if you use providers in the PPO´s network. PPO networks tend to be more loosely organized than HMO networks, and the law prohibits PPO's from requiring you to select a primary care physician. Also, unlike in an HMO, PPO PHYSICIANS AREN´T PAID FLAT FEES FOR THEIR PATIENTS. Instead, providers agree to charge the sponsoring insurer a contracted rate.

 

ADVANTAGES

Þ                  The standard co-payment is $10 for a routine office visit during regular hours.

Þ                  You may go to any specialist without permission, as long as the doctor participates in the network.

 

DISADVANTAGES

Þ                  If you see an out-of-network doctor, you might have to pay the entire bill yourself, and then submit it for reimbursement.

Þ                  You might have to pay a deductible if you choose to go outside the network, or pay the difference between what network doctors and out-of-network doctors charge.

 

Q.         WHAT DOES COBRA INSURANCE MEAN?

 

A.         The federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act) gives employees, and in some cases retired employees, the right to continue group health coverage for a period of 18 months for themselves, and up to 36 months for spouses or any dependent children. COBRA generally only applies to employees who lose coverage because of reduced work hours or lose their job for reasons other than "gross misconduct."

 

COBRA also enables a spouse and dependent children to continue coverage when an employee is entitled to Medicare, divorces, or dies. Employee´s children qualify for continued coverage under COBRA if they lose "dependent child" status under the rules of the health benefit plan. An employee, spouse, or dependent child has 60 days after qualifying for COBRA coverage to decide whether to take it. If accepted, the cost to the employee, spouse, or dependent child is the full premium, plus a 2 percent administrative fee. Depending on the situation, coverage may continue for 18 to 36 months, but may be slightly longer in some situations.

 

Continuation of coverage will end early if dependents obtain new coverage, premiums are not paid or the group policy is terminated.

 

Q.                  WHAT IS A HSAS – HEALTH SAVINGS ACCOUNTS?

 

A.         Health Savings Accounts (HSA) provide consumers with added insurance coverage and control. Flexibility is the key component of an HSA. Anyone with a high-deductible health plan can set up a health savings account to save money on medical care now, as well as save for future medical expenses. You may use HSA funds to pay for expenses that must be met before your deductible, to pay for services not covered by your health plan (such as alternative therapies or out-of-network providers), or insurance coverage during periods of unemployment.

 

Even if you purchase your insurance plan or your health savings account through your employer, you still own your account. You make the decisions on how much to contribute to your account and which medical expenses you will use the funds to pay. When you change jobs or move, the account remains intact. Any unspent balances remain in your account earning interest until you spend them on medical care.

 

An HSA can be a comforting safety net if you have a high deductible plan (remember, your plan won’t begin paying out until your financial responsibility is met). In the event that you lose a job, must seek uncovered medical services or just want to exercise your right to seek a specialist not contracted with your insurance plan, the funds in an HSA may one day be your saving grace. If you are a consumer who desires security and values freedom, an HSA is an option you should research.

 

Q.                  WHAT CAN I DO IF I AM TOLD MY INSURANCE WILL NOT COVER SERVICES?

 

A.      Many times patients are confused or misinformed on ways that they can take action to make a change to their insurance coverage. If you are employed and your employer pays your monthly health insurance premiums, all or any portion, it is important for you to speak with your Human Resources Department and/or Supervisor to discuss the possibility of changing or revising your current insurance plan benefits and/or potentially change insurance carriers.  If you are self employed, or carry your own policy, then I recommend that you speak with your insurance sales representative to discuss the same, as mentioned above.

 

Employers usually want to keep good employees, and offering a good employee benefit package is attractive when hiring and/or keeping good, quality trained personnel.  Many times, your employer may not be aware that there may be limitations or exclusions to the company’s insurance plan.  Your employer can call your plan administrator from the insurance company and discuss a potential policy change to add Orthotic and/or Prosthetic Coverage, or even look into making a change to another insurance carrier who does offer these types of benefits and plans.

 

Patients/employees must keep in mind that policy changes are typically done once per year, and usually in the last quarter of each year.  The sooner you discuss this with your employer, the sooner it can be evaluated for potential change.

 

Patients/employees must also keep in mind that by limiting or excluding certain types of insurance coverage and benefits from the insurance plan, this lowers the employers (or your) insurance premiums costs.

 

Good Points to Remember …Limited or Excluded Health Insurance Benefits, High Deductibles and High Co-Insurance means lower monthly health insurance premiums. While, Enhanced Health Insurance Benefits, Lower Deductibles and Lower Co-Insurance means higher monthly insurance premiums.

 

Q.                 HOW DO I KNOW WHICH PRACTITIONER TO CHOOSE FOR MY ORTHOTIC/PROSTHETIC CARE?

 

 A.        When deciding who to seek your Orthotic and/or Prosthetic medical care from, it is important that patient’s seek Orthotic and/or Prosthetic medical care from a Certified and/or Licensed Practitioner.  Certified and/or Licensed Practitioners have more extensive training and are qualified to provide Orthotic and/or Prosthetic medical device(s) to patients.  Below we have listed States that have Licensure Laws set in place, where non-qualified individuals should not be able to provide Orthotic and/or Prosthetic medical device(s) to patients.

 

            If you live in a State that is not listed below, it is highly recommended that you seek your Orthotic and/or Prosthetic medical care from a Certified Practitioner (Orthotist and/orProsthetist), and also make sure that they have ABC (American Board for Certification inOrthoticsProsthetics and Pedorthics) and/or BOC (Board for Orthotist/ProsthetistCertification) Credentials, that should be displayed on their office walls.  Patients should not feel intimidated to request practitioner credentials prior to receiving medical attention from Orthotic and/or Prosthetic providers.

 

            If you receive Orthotic and/or Prosthetic medical device(s) from a non-qualified Orthotic and/or Prosthetic provider, chances are you could receive the wrong type of medical device, and/or you may not receive the best possible quality patient care for these types of services.

 

           

ALABAMA 
Alabama Board of Prosthetists and Orthotists
Post Office Box 1052
Montgomery, Alabama   36101

Phone: (334) 420-1111
Fax: (334) 265-1281
Email Address: asbpo@bellsouth.net

Web Address: http://www.apob.alabama.gov/index.htm

 

FLORIDA 
The Florida Department of Health

4052 Bald Cypress Way, Bin #C 07
Tallahassee, Florida 32399-3257
Phone: (850) 245-4355 ext. 3620
Fax: (850) 922-8876
Email Address: MQA_OandP@doh.state.fl.us

Web Address: http://ww2.doh.state.fl.us/mqaservices/


GEORGIA 
Composite State Board of Medical Examiners
2 Peachtree Street, N.W., 36th Floor
Atlanta, Georgia 30303-3465
Phone: (404) 657-6488
Fax: (404) 651-7864
Email Address: medbd@dch.ga.gov

Web Address: http://medicalboard.georgia.gov/02/csbme/home/0,2458,26729866,00.html


ILLINOIS 
Illinois Department of Financial & Professional Regulation
 
320 West Washington Street 
Springfield , Illinois62786 
Phone: (217) 785-0800
Fax: (217) 524-6735
Email Address: http://www.idfpr.com/dpr/e_mail/prfgrp10.asp

Web Address: http://www.idfpr.com/dpr/WHO/orthot.asp

 

NEW JERSEY 
Orthotics & Prosthetics Board of Examiners
124 Halsey Street, 6th Floor
Newark, New Jersey07101
Phone: 973-504-6445 or 800-242-5846

Fax: 973-273-8035
Email Address: askconsumeraffairs@lps.state.nj.us

Web Address: http://www.state.nj.us/lps/ca/medical/orthotic.htm


OHIO 
State Board of OrthoticsProsthetics and Pedorthics

77 South High Street , 18th Floor
Columbus, Ohio43215
Phone: (614) 466-1157
Fax: (614) 387-7347
Email Address: bopp@exchange.state.oh.us

Web Address: http://opp.ohio.gov/


OKLAHOMA

Oklahoma Board of Medical Licensure & Supervision

Oklahoma Orthotists & Prosthetists

5104 N. Francis Ave. , Suite C
Oklahoma City, Oklahoma73118-6020
Phone: (405) 848-6841, ext. 113
Fax: (405) 848-8240
Email: rhall@okmedicalboard.org
Web Address: http://www.okmedicalboard.org

 

RHODE ISLAND 
Rhode Island Department of Health
Division of Health Professions Regulation - Prosthetic Licensure
3 Capitol Hill
Providence, Rhode Island 02908
Phone (401) 222-2828

Fax: (401) 222-3352
Email: Charles.Alexandre@health.ri.gov
Web Address: http://www.health.ri.gov/hsr/professions/professions.php


TENNESSEE

Tennessee Department of Health - Health Related Boards

Heritage Place Metro Center

227 French Landing, Suite 300

Nashville , Tennessee  37243

Phone (800) 778-4123 or (615) 741-7221

Fax: N/A
Email: TN.health@state.tn.us
Web Address: http://www2.state.tn.us/health/licensing.htm

 

TEXAS 
Texas Board of Orthotics & Prosthetics

1100 West 49th Street 
Austin , Texas78756-3183 
Phone (512) 834-4520

Fax: (512) 834-6677

Email: op@dshs.state.tx.us

Web Address: http://www.dshs.state.tx.us/op/


WASHINGTON Washington State Department of Health

Orthotics and Prosthetics Program
310 Israel Road SE
Tumwater, Washington98501
Phone: (360) 236-4834
Fax: (360) 586-4359

Email: hpqa.csc@doh.wa.gov

Web Address: https://fortress.wa.gov/doh/hpqa1/hps4/Orthotic_Prosthetics/default.htm



Information courtesy of:

Elizabeth Carlstrom, O&P Business Solutions


 

 

 

 

 

 

PO Box 2165
Round Rock, Texas 78680-2165
1.866.388.7110 Toll Free
512.388.7110 Local
512.388.7119 Fax
Visit our website @ OPBusinessSolutions.com



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