But, the doctor's office said. . .

Occasionally, a client will tell me, "My doctor's office said it would be covered (or would not be covered) by my health insurance." I hate to burst your happiness bubble but a medical office knows about, well, medicine not insurance. I don't try to diagnose medical conditions and they should not try to advise you about what is or is not covered by your insurance policy.



Here's why: Plans differ even when offered by the same insurance company. Someone may have a Cigna plan through their employer who happens to be the State of Tennessee. That plan will differ dramatically from a Cigna plan purchased by an individual or even provided through a different, perhaps smaller employer. Also, plans differ by deductible, co-insurance, maximum out-of-pocket and whether they have out-of-network benefits or not.

Which brings us to the one thing on which the medical office can advise you -- whether they are in- network for your plan. The overwhelming reason people become unhappy with their plan is because their doctors are not in network on their particular plan and this is a BIG ONE. If your doctor is not in-network with your plan, then you will either not be covered at all when you see that doctor and you will have to pay 100% of the charges if your plan does not have out-of-network benefits. If your plan has out-of-network benefits, you will have to pay the out-of-network amount. Your doctor's office SHOULD know which networks they accept from each insurance company. Yes, every insurance company has multiple networks. If you don't know the name of the network you are on, look at your card or call your agent.

Your agent may also be able to help you know whether or not your procedure is covered by looking at the summary of benefits for your plan. (An example of a summary of benefits is shown above.) You should have received a copy of this standardized form when you received information on your plan when you enrolled. It tell you everything you need to know about YOUR plan. If there is still a question, you may need to call your insurance company at the number on the back of your card for clarification.

Day 5: Today's Important Thing to know about Health Care Reform

One of the important things that the Affordable Care Act legislated was standardized benefits.  All policies sold going forward will have to include these benefits in order for them to be creditable. The standardized benefits are:

               Ambulatory patient services

               Emergency Services
               Maternity & newborn care
               Pediatric services including dental & vision
               Rehabilitative/habilitative services & devices
               Mental health & substance use disorder services, including behavioral health treatment
               Preventive & wellness services & chronic disease management
               Hospitalization
               Prescription Drugs
               Laboratory Services

You will notice that these standardized benefits include maternity, newborn care and pediatric services.  That means EVERYONE gets maternity benefits whether you are a 28 year old man or a 60 year old woman.  Of course, the premiums will also reflect that coverage.  One benefit of standardized benefits is that it makes it extremely easy to compare policies from different insurance carriers.  Now, you know today’s important thing about health care reform – standardized benefits.  Stay tuned for tomorrow’s important thing to know – the federally facilitated marketplace.