Maximize Your Health Insurance Benefits
ON THIS PAGE:
- Time Is of the Essence
- Health Insurance Glossary of Terms
- Opportunities for This Year
- Tactics for Next Year
When you need major surgery, health insurance can be invaluable. But it can also be confusing.
The patient advocates at The Center for Innovative GYN Care want to make your surgical experience as seamless and stress-free as possible, from the first phone call to your post-procedure follow-up visit. And we recognize that a big part of that is helping you understand and make the most of your health care insurance so you can concentrate on your procedure and recovery.
Our patient advocacy team takes a hands-on approach. They will coordinate contact with your health insurance company to confirm what your plan covers, calculate how much you may owe out of pocket, file any necessary claims on your behalf and more.
Talk to a CIGC Patient Advocate.
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As the final quarter of the year approaches, now is the time to speak with a member of our patient advocate team about using your remaining 2020 health insurance benefits — especially if you are planning to have surgery with CIGC before January 1, the date on which most health insurance plans reset and any unused benefits that are subject to a “use it or lose it” clause expire.
If you expect to have your GYN procedure after January 1, take care during the open enrollment period— typically held in the fall — to explore any changes you may be able to make to your health care benefits for the upcoming year that would help you plan for your care.
CIGC patient advocates will verify your plan’s terms and where you stand concerning the following elements of health insurance.
In network/out of network: In network refers to health care providers or facilities that belong to a health plan’s network of providers with which it has negotiated a discount and agreed to provide services to the network’s members. When you go to a doctor or provider who doesn’t take your plan, they are out of network.
Deductible: The amount you owe during a coverage period (typically one year) for qualifying services before your plan begins to pay toward your care. For example, if you have a $2,000 deductible and undergo a $2,500 diagnostic test, the first $2,000 of that bill would satisfy your deductible and your insurance would pay the remaining $500. Note that the plan may set separate deductibles for individuals in a family as well as for the family overall.
Coinsurance or cost-sharing: An all-year-long, across-the-board percentage you pay, after your deductible is met, toward a service or product while the insurer pays the rest. If your coinsurance rate is 20%, for example, and your doctor bills you $200 for an allowed service, you must pay $40 while your health plan pays the rest. Some plans pay 100% for allowed services after the deductible is met.
Copay: A set fee you pay whenever you receive certain kinds of health care services (outpatient surgery or behavioral health sessions, for example) or get prescription drugs.
Out-of-pocket limit or maximum: The total amount in health care costs (deductible, co-insurance and in some plans per-visit copays) you must pay before your plan will pay 100% of all qualifying costs for the rest of the year. As with the deductible, the plan may set separate out-of-pocket limits for individuals in a family as well as for the family overall.
Pre-authorization/referrals: A requirement set by your plan in which you must first seek approval from the insurer (pre-authorization) or a physician such as your primary care provider (referral) before you receive a specialized service. Failing to do so could result in your claim being denied.
Explore your options for planning your procedure at CIGC.
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CIGC understands how important it is to address GYN conditions in a timely manner and is committed to doing everything possible so that finances are not a barrier to treatment. Ask your patient advocate about flexible billing and payment options.
In the meantime, consider whether any of the following strategies could benefit you.
Check what you’ve spent. You may be closer to meeting your deductible and out-of-pocket maximum than you realized, meaning approved procedures such as your GYN surgery could be covered at 100%. Look at both individual and family thresholds if applicable; the latter, though likely thousands of dollars higher, may be easier to reach since expenses for all family members count toward it.
Take action on your FSA. A Flexible Spending Account allows you to designate a certain pretax amount of your gross income to pay for eligible health care expenses. The maximum contribution for 2020 was $2,750.
But you forfeit the balance if you don’t use all of the money, roll it over (up to $500) to an FSA for the following year or report how you spent the funds, all by a certain deadline. These deadlines include a grace period of several months and may vary by plan or employer.
Due to the COVID-19 public health emergency, the IRS eased some program rules this year, and you now might be able to opt into, out of, or adjust the amount you contribute to an FSA through the end of the year. This flexibility, however, is at the discretion of the employer. Your employer’s human resources department can provide details.
Next steps: Decide whether it’s more beneficial to use any remaining funds for your GYN procedure this year, roll unused money over into an FSA for next year or decline another FSA and use your money some other way.
Go high with an HSA. Health Savings Accounts work similarly to Flexible Spending Accounts but have major differences.
With an HSA, you can designate a portion of your pre-tax earnings to go toward paying approved health care expenses. However:
- HSAs continue to build indefinitely and can be invested, with interest accruing tax-free.
- They are portable and remain with you even if you change jobs.
- The maximum yearly contribution is higher than with an FSA; 2020’s individual cap was 3,550.
- You can make contributions to the 2020 limit until mid-April 2021.
- You can deduct your HSA contribution from your current taxes.
If there is a “catch” with HSAs, it is that unlike FSAs, they are only available as part of a high-deductible health insurance plan, and high deductibles are not advantageous for everyone. You will need to determine whether you would like to shoulder medical expenses entirely out of pocket until you have reached the ceiling. If you can, the tax advantages might be worth it.
Compare your spouse or partner’s plan to yours. If each of you has individual coverage at your respective workplaces, compare your benefits to determine which options will best suit your upcoming medical needs.
Prepare for change. During open enrollment season, you may very well find that your employer will be offering a different plan (or plans) for the new year than you had this year. Even if they keep the same insurance provider, deductibles may increase, covered services may shrink or expand, medication formularies may be different, etc. As soon as plans are unveiled, look closely at your options and make sure you’ll have the care you need.
In addition to the assistance provided by our patient advocates, CIGC works with most major insurance companies and continually seeks better rates and participation in additional plans.
Get help planning for your GYN care today. Talk to a CIGC patient advocate.
|Schedule a Consultation|
CIGC is dedicated to providing information and materials for women to help navigate the complicated health care system. The CIGC founders, minimally invasive GYN surgical specialists Paul MacKoul, M.D., and Natalya Danilyants, M.D., developed their advanced GYN surgical techniques using only two small incisions with patients’ well-being in mind.
Their personalized approach to care helps patients understand their condition and the recommended treatment so that they can have confidence from the very start. Our surgeons have performed more than 25,000 complex GYN procedures and are constantly finding better ways to improve outcomes for patients.