The Patient Protection and Affordable Care Act, more commonly known as Obamacare, provides coverage for medical services to protect and promote health. All Obamacare and Medicaid policies in Michigan are required to include the same basic services for their patients. These services are called the Essential Health Benefits. They include all of the following:
- Outpatient care
- Emergency room visits
- Inpatient hospital treatment
- Prenatal and postnatal care
- Mental health and substance use disorder services: behavioral health treatment, counseling, and psychotherapy
- Prescription drugs
- Lab tests
- Services and devices that assist in recovery if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
- Preventive services including counseling, screenings, vaccines, and care for managing a chronic disease.
- Pediatric services: This includes dental care and vision care for kids
While these services are covered by all insurance policies, the cost the consumer may have to pay for these services can vary widely. The consumer portion of the covered medical services will depend on who provides the services and the following key costs factors described in each insurance policy. The best way for consumers to control their medical costs, is to understand the rules associated with your insurance policy.
In Network Services -All insurance companies have established relationships with medical providers. These relationships are call “networks.” Consumers limit their costs if they select a medical provider that has a relationship with your particular insurance company. When you use the services of a medical provider that has a relationship with your insurance company, they are called, “in network services.” The customer always pays less if the medical services are provided by “in network medical personnel.” When the consumer needs non-emergency care, it is always best to call your insurance company or look on the insurance company website to find an “area network provider” that can provide the service.
Co-Pay-This is the set fee an insurance company charges a customer to use a specific medical service. For example, an insurance company may charge consumers a fee of $25 for an appointment with a doctor or primary care physician. It is important to know what the co-pay is for all covered services before making an appointment. The co-pay charged for the service is less expensive for “in network” providers.
Deductible –This is the amount the consumer has to pay before the insurance company will pay for any covered medical treatments. The consumer payments for medical services must equal the amount of the deductible. Once the consumer pays the deductible, then the insurance company will pay their share of the treatment costs. The monthly premium payment is not counted as part of the deductible. In some cases, the deductible must be paid even before the insurance company will pay for the patient’s office visit. The consumer can still make an appointment to see the doctor, but the insurance company may not pay for any of the medical costs associated with the appointment until an amount equal to the deductible has been paid by the consumer.
If the person is single, the insurance company deductible amount is only for the individual on the policy. It the consumer has a family policy, in many cases the deductible applies to the entire family. The insurance company will keep a record of how much of the deductible the individual or family has paid for medical services. This record of payments usually starts January 1st and ends on December 31.st Therefore, as the consumer is making medical appointments, it is important to keep track of the amount of the payments will count towards the deductible.
Co-insurance-This is the percentage of approved medical services that will be paid by the insurance company. The co-insurance amount is paid once the deductible has been paid by the consumer. For Obamacare policies, the co-insurance amount can range from 60% to 90%.
Total Out Of Pocket Costs-This is the maximum amount or payments an individual or family might make for medical services for the entire year. After the individual or family pays this amount in medical charges, the insurance company will pay all of the remaining costs for approved medical services for the rest of the calendar year. This record of payments usually starts January 1st and ends on December 31st.
Understanding these insurance terms will assist the consumer in knowing how to control their health care costs. Please go to healthcare.gov for more information on understanding and controlling healthcare costs.
By Tsu-Yin / Professor & PhD Program Director
Eastern Michigan University School of Nursing