How to Get the Most out of your Health Insurance Benefits in 2016

By PokitDok Team,

Controversial as the Affordable Care Act has been, it has helped turn millions of Americans into smart healthcare shoppers. Nearly 90% of Americans have health insurance, according to the U.S. Census Bureau, with high-deductible plans being the fastest-growing category of coverage. That means a significant part of the country is looking to maximize the benefits of their coverage.

Here are six ways to make health insurance benefits go further in 2016 — and a few ways we can help healthcare companies offer these experiences to the consumers with whom they engage.


Use Insurance Provider Intel and Bargaining Power

Healthcare providers charge different rates, depending on the insurance company and plan, according to Consumer Reports. Sometimes, the difference in price can be dramatic - hundreds or even thousands of dollars. If a patient hasn’t met his or her deductible for the year, the recommendation is to shop around, which is a pretty new concept for many. Considering this, consumers should have direct access to their eligibility and the proper tools to best take advantage of their benefits. While many patients, as of now, have no option but to call their insurance companies directly, what if they could immediately access this information as easily as say, searching for a flight on PriceLine? With PokitDok’s free of charge X12 APIs, specifically our eligibility endpoint, businesses can offer their consumers direct access to their eligibility information in a clean, easy to understand way. Try it out by signing up for our Platform or check out a past post for more on X12.

In the meantime, “providers can participate with dozens of plans and may have no way of knowing what yours pays them before you file the claim,” Consumer Reports writes. “But the insurance company will know.” Until this experience is universally automated via the use of APIs in the business of health, patients should double and triple check with their insurance plan before engaging in costly procedures and subsequent claims submissions.

To help demonstrate the importance of shopping for healthcare services, a team in Connecticut found a price discrepancy of $3600 for a vaginal delivery from one hospital to another. The research also found that services that don’t require an overnight stay (“examples would be lab tests, X-rays and walk-in surgery”) can be as much as five times cheaper at a clinic or doctor’s office than if you had it performed at a hospital.

To help introduce transparency into this process, one of our customers recently launched a version of our private label marketplace to allow patients to shop, book, and pay for imaging services. Patients are encouraged to understand their benefits on the front end and, if they have a high deductible health plan where they would be paying for this service out of pocket anyway, they are given a discount by paying at checkout. The price they pay can then electronically be submitted to count toward their deductible.



Consider Putting Aside Money in a Flexible Spending Account

Employers can set up Flexible Spending Accounts (FSA) and divert pre-tax salary into it. This lets people pay some healthcare expenses with untaxed money, and it can save hundreds on an annual basis. Selena Maranjian at The Motley Fool did a little math on FSAs for the 2015 tax year, and she found many people used them to save more than $600 each year. The same savings she calculated from 2015 also apply to the 2016 tax year.

Here is an example: For 2016, the maximum amount of money a patient can put into an FSA is capped at $2,550, and let’s say a person opts to max out that account this year. That’s $2,550 that can be spent on healthcare expenses. If that person were in the 25% tax bracket, the cost would have only been $1912.50 from their salary, so he or she would save almost $640 in taxes by earmarking that pre-tax money for medical expenses.

Also, FSAs are not the same as Health Savings Accounts (HSAs), which are only available to people with high-deductible insurance plans. Anyone can have his or her employer set up an FSA.

There are three important things to know about managing your FSA.

First, only certain procedures, services and products are FSA-eligible expenses. Fortunately, there are some common health-related items that qualify, including contact lenses, dental procedures, and even sunscreen with an SPF of 30 or higher. Aetna has a complete list of this expenses here.

Second, you have to save receipts and claim reimbursement at the end of the year. WageWorks has a nice guide to FSA, and it reminds people to make sure each receipt includes the following:

  1. The patient’s name, in case a medical service was rendered. If you buy an item from a retailer, don’t worry about this information.
  2. The provider or merchant’s name.
  3. The date when the service was rendered or the item was purchased.
  4. The type of service, or a detailed description of the item purchased. “A bag tag is sufficient for prescriptions,” the guide notes.
  5. The cost of the product or service.

Finally, FSAs have a use-it-or-lose-it policy. These accounts reset at the end of the year (though it varies from company to company whether the end date is Dec. 31 or at some other point in the year). If the end of the fiscal year is approaching and a patient still has money in his or her FSA, this is a good opportunity to take care of some healthcare procedures or to stock up on necessary supplies.

Fox Business has a few tips for prioritizing your end-of-year FSA spending:

  • “Start by tackling any items on your healthcare to-do list. The co-payment for that annual eye exam that you've been putting off can help drain a leftover balance.
  • “Then, go through your medicine cabinet to look for anything that is expired or needs a refill. You may need a doctor's prescription in order to expense over-the-counter medicines like aspirin.
  • “Don't buy too much of any one item. Some account administrators will reject claims that point to stockpiling.”



Patients Should Keep an Eye Out for Freebies

Any insurance plan that went into effect after the Affordable Healthcare Act was signed in March 2010 is legally required to pay fully for certain preventive services, even if a patient hasn’t yet met his or her deductible.

These free preventive services include:

  • Immunizations
  • Blood pressure and cholesterol screenings
  • Obesity and Type 2 diabetes screenings
  • Depression screening

For children, certain additional services are available, which include:

  • Developmental screenings
  • Autism screening
  • Behavioral assessments
  • Vision and oral health screenings

And for women, another 22 preventive services are available, including:

  • Contraceptives
  • Well-woman visits
  • Osteoporosis and anemia screenings
  • Prenatal care
  • Mammograms and breast cancer counseling

You can find the full list of available services here.

Claiming these freebies might require a little vigilance on your part, however. As Elizabeth Renter at U.S. News & World Report points out, “Your doctor's office may bill a visit separately from your preventive services. If this is the case, you might have a copay. You might also have to pay if the primary reason for your appointment is something other than preventive care. You’ll also likely have to pay out-of-pocket for treatments and follow-up appointments with your doctor if those screenings reveal a problem.”

A few other exceptions Renter mentions:

  • Treatments revealed by a free screening will likely cost money, whether from your deductible or as a co-pay.
  • Some insurers only offer one type of contraceptive. “So, if you want a vaginal ring, but the insurer offers alternative methods also considered ‘hormonal birth control,’ you could be stuck with a bill,” she writes. “Likewise, opting for brand name over generic could leave you with cost-sharing responsibilities.”
  • Going out-of-network for these free services will likely cost you, too.

To be sure your doctor knows to bill your insurance for qualified preventive care, be very explicit about why you are making the appointment. "To set up a well-woman visit that's free, you might need to say on the phone when you're making your appointment, 'I want my free well-woman visit,'" Christina Postolowski, health policy manager with an organization called Young Invincibles, told the Los Angeles Times. "Not everyone knows to do that, so they may be charged a co-pay later because the office thought it was just a general appointment."

Finally, individual plans may carry their own free perks. Healthcare Plain and Simple points out that some plans cover a free pair of eyeglasses or an annual flu shot, for example, so it’s important for people to be proactive and know what they’re entitled to.

Further, it’s also important for members of the healthcare world to build better, intuitive patient experiences that naturally give patients the information they need, when they need it. Our Eligibility API endpoint and the front end we’ve built to demonstrate its offerings does just that. Want to see it in action? Contact us.



Strategically Plan Out Elective Procedures

Heidi Rasmussen, co-founder of freshbenies, has an awesome post on how to balance elective procedures with your deductible and your out-of-pocket max. Here is a summary of how she recommends optimizing your coverage for an elective procedure.

  • Do it early in the year in the year to meet as much of your deductible and out-of-pocket max as you can. If you meet your deductible early, the rest of the year’s medical expenses will be covered.
  • If you wait until after you’ve reached your deductible, “[t]his doesn’t necessarily mean that every medical expense is covered from here!” she says. “Be sure to look at your policy for the difference between your deductible and your out-of-pocket maximum. Then, get an estimate on the cost of the procedure to see if it makes sense to do it now.”
  • If you’ve already reached your out-of-pocket max, she says, go ahead and have the procedure done now.



How to Take Advantage of High-Deductible Plans

First, as the Consumer Reports guide points out, patients should try to get as much as they can out of their co-pays. “For example, if [someone has] a sore throat, [they should] go to a doctor's office, which charges a copay, rather than the emergency room, which [that patient] will likely have to pay for in full unless [he or she has] met [their] deductible,” the team writes.

Karen Datko at MoneyTalksNews recommends looking into an HSA, which lets the tax-free money you deposit roll over from year to year. For 2016, Datko reports, HSAs are capped at $3,350 for individuals ($4,350 for people older than 55), and $6,750 for families.

Finally, Datko also recommends you ask your doctor whether there is a discount for paying in cash. Many doctors love cash patients, and as Datko says, “You may even find that a doctor will give you a considerable discount if she knows you have to cover the entire cost out-of-pocket.”
images by: Todd Quackenbush, geralt, frolicsomepl, lazare, skeeze

The opinions expressed in this blog are of the authors and not of PokitDok's. The posts on this blog are for information only, and are not intended to substitute for a doctor-patient or other healthcare professional-patient relationship nor do they constitute medical or healthcare advice.

  Tags: API, Dev, Healthcare consumerism

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