Make The Most Out Of Your Health Plan

By Editor Guest on May 2, 2018
Posted in Latest Updates

Healthcare doesn't have to be confusing. That's why we've put together a monthly e-series!

This month learn how to get the most out of your health plan, connect with your provider during your first appointment and decode health terms.

Understanding Healthcare Terminology

While the plan document will be able to give you a clearer look into what the plan covers and what your out-of-pocket costs are, sometimes understanding the difference between healthcare terms can become confusing. Below you will find a quick guide to help you understand health plan terminology and what it means to you.

Health Terms to Know

  • Premium: The monthly fee you pay for your insurance.
  • Deductible: How much you'll pay for care first, before the insurance plan pays for anything.
  • Deductible does not apply: You will not have to meet your full deductible before the insurance plan pays.
  • Copayment: A fixed amount you will pay for routine services to which your deductible does not apply.
  • Co-insurance: A percentage you must pay for care after you've met your deductible unless it is a service where the deductible does not apply.
  • Out-of-pocket maximum: The absolute max you'll pay annually.

Need more guidance? Keep reading for scenarios and full definitions. Remember that your plan document will help you figure out what applies to you based on the care you need. If you use the plan document in tandem with these terms you can better understand your responsibility and the health plans.

A premium is an amount that is paid into the insurance plan on a monthly basis. Your employer provides a set amount per employee each month that goes toward your premium. If you have additional dependents on your plan, you will be responsible for covering the remaining amount. The remaining amount is typically deducted from your paycheck as pre-tax dollars. 

To understand the amount you will be responsible each month, please refer to the Trust's premium rate sheet.

Your deductible is how much you'll pay for care first before the Trust will pay for services. In most cases your deductible will need to be met for healthcare (such as surgical procedures or hospitalizations) before the Trust will cover your claims.

For example, the Trust's individual deductible is $600. If you undergo two procedures that are $600 each, you will be responsible for meeting your deductible for the first one, and your second procedure will be covered at 80 percent of the contracted rate by the Trust.

Deductibles do not apply to preventative health checkups and many basic routine health services. Essentially that means you do not have to pay $600 to see a doctor for a sick visit, instead, you will be charged a co-payment or a coinsurance.

Your copayment is the fixed amount you will pay for routine services as defined in the plan document. The copayment is for services medical, pharmacy, dental and vision, but varies based on service rendered.

Similar to a copayment, a co-insurance is generally applied to less routine services and is expressed as a percentage rather than a fixed dollar amount like a copayment.

The co-insurance typically starts after you've paid your deductible. There are some instances in the Performance Plus Plan that this is not the case. Always refer to the plan document for clarification.

The co-insurance you will owe is based on contracted rates. This is why it is difficult for someone to quote your responsibility immediately. Therefore, it is advised to work with your doctor's office ahead of time, or request an estimate based on the service recommended, before receiving care.

Out-of-pocket maximum
Your out-of-pocket maximum limits the amount you can pay each calendar year for healthcare including copayments, deductibles and co-insurance. Once you have met your out-of-pocket maximum, no other costs can be collected throughout the remainder of the year.

The Importance of Health Maintenance (Well Care vs. Sick Care)

All too often people succumb to thinking you should only use your healthcare when you are sick instead of focusing on staying healthy and catching any long-term health complication before it is too late to treat. There is zero benefit for you to have this mentality. Seeking out health maintenance care is not only beneficial long term for your health, but it can also help your out-of-pocket costs over the years.

The objective of well care is to support your body so that you can heal yourself by addressing the causes of disease rather than the symptoms. Well care focuses on your mental and physical outcomes to ensure you can enjoy a full life. While sick care focuses on treating your symptoms rather than the cause.

Role of Your Health Plan in Your Health Journey

The Teachers Health Trust has two teams dedicated to getting all of your questions answered quickly and clearly - the Healthcare Advocates and the Service Team. Both teams share a common goal of helping you navigate your healthcare and live your healthiest life.

When you need to know which team to call, use this guide to help you know who to  dial-up.

MedImpact is your pharmacy benefit manager. They process the traditional retail pharmacy claims based on the plan design that is explained in your summary plan description, with the exceptions of most specialty pharmacy medications. They also maintain eligibility in their system. If you or your dependents are denied a prescription for any reason, you can contact their customer service for further details and explanation.

Welldyne Rx is your mail order vendor as well as your specialty pharmacy manager. If you or your dependents are currently taking a "specialty" medication, that prescription will be filled by US Specialty, a subsidiary of Welldyne. Welldyne is responsible for the Prior Authorization process for all medications that they dispense through the Specialty Pharmacy.

To fill your everyday prescriptions your in-network pharmacies are CSV, Vons, Sams Club, Walmart and Lin's Pharmacy in Overton. You can fill your prescriptions at an out-of-network pharmacy, but there will be a $10 out-of-network charge.

Case Management
Complex Case Management program is supported by a team of dedicated registered nurses who work as case managers. Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.

Complex Case Management consists of the following processes:

  • Participant Identification & Selection
  • Care Assessment
  • Care Plan Development/Update
  • Care Plan Implementation
  • Care Plan Monitoring and Evaluation

Case management involves comprehensive assessment of your condition, determination of available benefits and resources, and development and implementation of a case management plan with performance goals, monitoring and follow-up. All participants have the right to participate or to decline to participate.

Over the last decade, the way care is administered to patients in the hospital has changed dramatically. In the past, a hospitalized patient was admitted and cared for by his/her primary care physician. But as the office load for primary care increased and more efficient utilization of hospital resources became a high priority, a new physician specialty evolved: the hospitalist. This physician is dedicated to the delivery of comprehensive medical care to hospitalized patients and generally works with case managers to help manage the hospital stay. Performance of hospitals and the healthcare system is improved by:

  • Prompt and complete attention to patient care needs.
  • Employing quality and process improvement techniques
  • Collaboration, communication and coordination with all physicians and
  • healthcare personnel
  • Safe transitioning of patient care within the hospital into the community
  • More efficient use of all hospital and healthcare resources

The Teachers Health Trust utilizes a team of hospitalist physicians and staff provided by HealthCare Partners. Anytime a Trust patient is admitted to one of the 14 area hospitals, a hospitalist from this group will be guiding your care toward the best possible outcomes.

How to Connect with Your Primary Care Provider (PCP) During Your First Appointment

An integral part of the Patient-Centered Medical Home (PCMH) model is the relationship with your primary care provider (PCP). Just as with any new relationship, it can take time to connect with a new doctor. Your PCP is going to be your partner to better health by helping you coordinate your healthcare needs. It is important to start with a foundation of trust and honesty. Below are three tips to help you start to building a great relationship with your PCP.

  1. Bring your whole health history. Many times, people believe their PCP only wants to know about your medical history, your family tree (up to grandparents) and any medications they are currently taking. However, a key piece is missed if you believe this is the case. It is also important to share with your PCP any mental or behavioral health issues you may be experiencing, have a family history of or have experienced in the past. Whether you suffer from high blood pressure or anxiety and panic attacks, it is equally important to share both conditions.
  2. Talk about your health goals in detail. For example, many patients believe telling their doctor they want to lose weight is enough, but without proper detail it can be difficult for a doctor to personalize a care plan for you. Instead of telling your doctor you'd like to lose weight, tell them you want to lose X number of pounds by X date. Let them know what you are doing already and then start the conversation around how to enhance or harness your goals better.
  3. Discuss your lifestyle and ask for alternative ways to be connected. For example, share if you work unique hours or have to travel a lot. The best  thing you can do is be honest and ask them if they offer virtual care visits, the ability to be seen after hours, etc. Telling them what you need in care and working toward compromises for them is a great way to ensure everyone has correct expectations.

It is important to make sure you schedule a 20-minute well visit for your first time meeting a new doctor. Do not feel rushed and use that quality time to deep dive into your personal health and your personal health goals. Doctors have heard it all, nothing should be embarrassing and if it may be for you, write it down and give it to them so you do not have to speak it out loud. A primary care doctor's main goal is your whole health, not to judge you.