As one of our most important territories, Guilford County and all of Greensboro is covered by our premier agent David Bentley. With Greensboro offering a $0 premiums for Medicare with prescription drug benefits in 2019, now is the time to contact our agency to lock in these extremely low rates. You can be rest assured our team will go above and beyond to help you get the lowest monthly payments for your health insurance coverage.
In the last two decades, Greensboro has grown from 200,000 people to around 290,000 people. With Charlotte, Raleigh and Wilmington all seeing double digit population growth over the last few decades, it should come as no surprise that Greensboro is also growing. Greensboro’s neighbor, Winston Salem, has also grown at around the same pace. With a plethora of jobs and educational opportunities in Greensboro we expect to see more people move into the area in the years ahead.
Note that in 2019 there will be an opportunity for Medicare patients to have a $0 premium including prescription drug benefits. In the past, the Medicare premium was around $55-$60 a month. Do not miss out on the opportunity to save quite a bit of money each and every month. This could be a savings of over $600 a year.
As a Blue Cross Blue Shield of North Carolina health insurance agency, we assist families and seniors that are seeking health insurance. We also work with those hoping to find temporary or self employed insurance. Those seeking short term health insurance, in between jobs, can reach out to us at any time. We will work with you to find an affordable Blue Cross NC plan that fits your needs. We also have a professional staff that can answer any questions or concerns you may have.
Health Insurance Types Lecture
Other types of health-related insurance are your disability insurance, automotive insurance that are related to injuries and workman’s compensation. Obviously, we talked a little bit about you have insurance, you pay a premium for that insurance. So every month you pay a premium to the insurance company to keep your insurance policy in effect. We’re all familiar with premiums. Now let’s talk about some health care insurance plans. Your basic insurance plan is called an indemnity plan. It provides protection against loss, which is health care loss. There is no provider network.
So, when we’re talking about network, a network is a group of providers having participation agreements, which is a contract with a health plan. One thing about an indemnity plan is it pays the same whatever, the same, whatever physician or hospital you go to. With an indemnity plan you will always have a deductible and then you’ll have your benefits, which are 80-20, 70-30, 90-10. The top number is the number the insurance company pays, the bottom number is what the patient is responsible for, or if they have a second insurance that’s what you send to a second insurance. So when I talk about 80-20, the insurance company pays 80% of the fee you pay 20%. Okay.
Physicians send the health care claim. When we’re talking health care claim, there are two basic health care claims. Everything in the outpatient world is a CMS1500 form, everything in an inpatient world is a UB 04. All of the information from a CMS 1500 form goes out of UB 04, but a UB 04 is used by hospitals and facilitie,s and that has four more codes because obviously, hospitalization is a little bit more complicated than going and having an X-ray or a lab test or just going to the doctor’s office. So physicians and the health care claim, which is the formal insurance claim, which reports data about the patient services to the payer on behalf of the patient.
Fee for service, I kind of talked a little bit about this with insurance companies’ budget. So everything has a fee, as a one-view chest x-ray has a fee, a two-view chest x-ray has a fee. A office visit for level one has a fee, office visit level five has a fee. Everything, when we get in we’ll talk about codes later in the book, every service has a code that identifies what that service is, and every service has a fee. Most policies have a deductible and that deductible is the amount the insured pays for covered services before the benefit begins. So if I have a $500 deductible, I just don’t pay $500. I have to go to the doctor, to the hospital to have laboratory, have X-ray. I have to have a whole bunch of services until that $500 worth of medical services is covered by me, paid by me. Then I have satisfied my deductible.
At that point, the insurance company benefits will now kick in, which is the 80-20. So as soon as I’ve had enough services to cover that $500, then the insurance company will then start paying their 80% and I still pay the 20%. The 20% I’m talking about is the co-insurance. This is the lower number, always a lower number. It’s the percentage of each claim which is paid by the insured. Okay? The co-insurance is either paid by the insured or sent to a second insurance company. It used to be that many of us had two insurances, that’s why it was called a co-insurance amount. Obviously, with the economy and insurance costing as much as it is, not all of us have two insurances. A lot of children do because both parents may be working and both parents may cover them, because obviously children go to the physicians a lot more than adults do on a usual basis. Okay.
Out of pocket expenses. Out of pocket means everything you have to pay out of your pocket, that’s your deductible, that’s your co-insurance. Insurance companies set a limit to that out of pocket. So I have, let’s just say my benefits are a $500 deductible, let’s just say I have a $2,000 deductible. My insurance pays 80-20, to and out of pocket of a $100,000. So what that means is I pay a $2,000 deductible and I pay all those 20%. Okay. So let’s say I have the services out of a hospital that cost, you know, half a million dollars. Well, my 20% of that is a 100,000.
So half a million dollars’ worth of medical care, you know, I get into a major auto accident, I’m going to be having lots of X-rays, MRIs, lots of broken bones, surgeries, hospital visits, it’s going to be very easy for me to get up to a half a million dollars’ worth of medical bills. Well, remember the insurance pays 80-20, so 20% of that half a million dollars is a $100,000 plus my $2,000 deductible. So I’ve paid a $102,000. Well, once I reach my out of pocket of a $100,000, the insurance company will pay 100%. So when you hear that out of pocket amount, that’s usually the out of pocket maximum that a patient is responsible to pay before the insurance company will then pay a hundred percent.
Managed care. We talked about an indemnity plan, an indemnity plan has no networks. Now when we get into managed care, managed care offers a lower cost healthcare because they negotiate fees with doctors. Remember that fee schedule and fee for service? They negotiate fees with doctors and providers and hospitals and X-ray places and laboratories, they negotiate that fee. So they negotiate a lower fee, which means your premium is lower. However, you are restricted as to the choice of providers because you must go in network. You must go to a provider that have signed a contract with that insurance company.
A managed care organization establishes links between providers, patients, and payers. Participation allows a provider to contract with a health plan to gain more patients and lower fees. How does a physician gain more patients? Well obviously, when you have a managed care plan you are given a book. Here are all the positions that are in network, pick one. Well obviously, you’re going to pick one. So the physicians are going to gain more patients. Some managed care plans are called capitation, and capitation is a fixed prepayment to a provider for all medically necessary services. The physician is paid a per member per month rate.
So what this means is the insurance companies assigns Dr. Jones 10 patients. They pay Dr. Jones a $100 per each of those patients per month. So Dr. Jones gets for 10 patients at a $100 each he gets a check for a $1,000 every month. He gets paid whether the patients come in or not. So January no patients come in, he gets a $1,000. February no patients come in, he gets a $1,000. March, no patients come in, he gets a $1,000. However, if you get a month that all 10 of those patients come in and they all come in three to four times, he still gets a $1,000. Next month if all those patients come in again, he still only gets a $1,000. He or she, the physician only gets a $1,000.
So when you have a capitated agreement you have to kind of think in a different term, you have to manage the patient’s care a little bit better. Because obviously, you want them healthier, and you don’t want them coming in as much or needing as many expensive services because you’re only going to get paid a $1,000 no matter what you do. So you have to think a little bit differently, instead of waiting for the patient to call you when they’re sick, you need to make sure that patient is well, make sure that patient comes in for their yearly annual exam, make sure that patient is taking their medicines, they go for their x-rays, et cetera. So you have to have a little bit different philosophy on practicing with those 10 patients than you do with the other patients. That’s because you’re in a capitated agreement and you’ve already gotten that money upfront.
Now, when we get into the types of insurances, we talked about indemnity, which is your basic no network at all for anything. You pay the same no matter where you go, okay. You have a deductible and your benefits are 80-20. Okay. When you get into your managed care, we have three types of managed care plans, your HMO, your PPO, and your POS. So the version we’re going to talk about is our HMO, and this combines coverage of medical costs and delivery of health care for prepaid premium, because obviously you still have to pay for insurance.
Network is a group of providers having participation agreement, which means a contract. With an HMO, you must go to physicians in your book and in your book only. You cannot go to any other physician and have insurance. If you go to another physician that’s not in your book, that means you have to pay 100%. So visits to out of network providers are not covered except for emergencies. Obviously, if you’re traveling out of state or are right next to a hospital or get into an auto accident and you’re taken to a hospital that’s out of network. Obviously, there are exceptions to the rule for emergencies.
However, non-emergencies, you better be going to a physician within your book. HMO’s require pre-authorization before the patient receives services. So you need to call your PCP, which is down here at the bottom, which is your primary care doctor. He or she is also called the gatekeeper. You have to call them and ask if you want to go to a dermatologist. If you have a bad skin rash you have to call your primary care doctor and you must see them first. Then they will pre-authorize if you can go to a dermatologist.
Same with if you break your leg. Obviously, you need to call your primary care physician and you need to say, “Do I need to come to you or can I go to an orthopedic doctor?” It’s up to your primary care doctor, your gate keeper, to determine where you’re going to go. Pre-authorization must be done before those services are rendered. With an HMO, you have a copayment. So you know that any time you go to a doctor for preventative medicine, you don’t have to pay anything.
You go to a doctor when you’re sick, you’re going to have to pay $20. You go to an urgent care, you’re going to have to pay $50. You go to an emergency room, you’re going to have to pay a $100. You go to have a mammogram, you’re going to have to pay $35. You know what you’re going to have to pay upfront, right upfront, you know what it is. So it’s nice and easy, you know, I got to go to the doctor, I have to take $20 with me. That’s what an HMO is, so you know you have a co-payment, and you have to pay that money upfront before the service is rendered.
Referral, referral is transfer of patient care from one physician to another for a condition. For example, if I develop heart problems, my physician is going to refer me to a cardiologist for my heart. I still go to my main doctor, I still have my family practice doctor, my internal medicine doctor who takes care of everything except my heart. My heart is now being taken care of by that cardiologist because my physician has given me a referral to that cardiologist.
The second type of managed care plan is a point of service, this gives you a little bit more flexibility. You have your book with all those physicians in that are in network. However, you can still go to out of network physicians, but you have to pay a little bit more out of pocket. So here’s how your benefits would sound if you had a place of service or a point of service type of plan. You have a $500 deductible in network and your benefits are 80-20. Out of network, you have a $500 deductible and your benefits are 60-40. So you can go to an out of network physician but your out of pocket costs are going to be more. You’re still going to have your $500 deductible but you’re going to have to pay that 40% co-insurance.
Plus, because that doctor doesn’t have a contract, if that doctor charges more than the fee that your insurance company has set you’ll also have to pay that amount. So with a point of service you have more flexibility. You can go to a dermatologist if you want to and you don’t have to ask a primary care doctor because you don’t have a primary care doctor in a point of service plan. Usually, you pay a little bit more as far as premiums for a point of service plan but you have more flexibility.