Deductibles, HSA, High Deductible Plans, What Does All This Mean?

We field numerous calls regarding insurance benefits. Parents want to know why they have a balance with us and if insurance paid for the services.  

Our office accepts a variety of plans. Each is underwritten by a person’s employer and the insurance company. What this means is that each plan is completely different from the other.  Even two BCBS health insurance plans may be different when it comes to benefits. As a result, it is difficult for our office to know every patient’s specific plan.

However, there a few basic concepts that we suggest parents become familiar with so that they have a better understanding of terms and why you have a balance with the doctor.  

DEDUCTIBLE

Deductible refers to the total amount of covered medical expenses that must be paid by the patient before the insurance company begins paying benefits.  After this requirement is reached, the insurer will begin paying according to terms of the contract (often 75%-85%) of covered medical costs.

COINSURNACE

The coinsurance is the cost-sharing portion of the medical expense the patient is responsible for. For example, the terms of the contract state a coinsurance of 30%. In practical terms, this means that your insurance plan covers 70% of your medical benefits, and you are responsible for 30% of the cost.

The coinsurance is generally in addition to the copayment. In other words, even if you have paid a copayment, you may be responsible for a portion of the medical bill if your plan has a coinsurance amount.

FLAT-RATE COPAYMENT

The flat-rate copayment is when a patient pays a share of the covered medical costs, and the insurance carrier pays an amount based on the policy.  For example, when the patient pays $15 of any office visit charge or $3 for any prescription, the insurance carrier is responsible for the balance.

Copayments are non-negotiable at our practice. We are contractually obligated to collect the copayment at the time of service. Furthermore, copayments are required to be collected for virtually every single office visits, including follow-up visits.

PERCENTAGE-BASED COPAYMENT

This cost sharing option is when the patient pays a percentage share of covered medical costs, and the insurance company pays an amount based on the patient's policy.  Examples: 20% of the office visit charge - $10 of a $50 charge, $12 of a $60 charge, etc.  Typically this copayment arrangement includes a deductible and may have other variations.

CONSUMER-DRIVEN HEALTH PLANS (CDHPs)

CDHPs are the fastest growing plan type currently across the country.  Employers are shifting financial responsibility to their employees by offering health plans with high deductibles and coinsurance to reduce the cost to the business.  

Most plans cover wellness services such as immunizations, well-child visits and periodic check-ups more than sick services.  They usually have a high deductible, but when the deductible is met, the plan pays for services at a percentage (such as 80%) of a defined reasonable and customary fee schedule.

CDHP are attractive because premiums are lower than non-CDHP plans. Keep in mind that the reason premiums are lower because the health insurance company shifts more of the risk to you, the patient. You are on the hook for paying for medical services before the health insurance begins to pay for their portion.

For example, if your plan has a $5000 deductible, the subscriber is on the hook for $5000 before the insurance company begins to cover for medical benefits. 

HEALTH SAVINGS ACCOUNT (HSAs)

HSAs are tax-favored savings accounts funded with pre-tax dollars by the individual or the employer.  Money can be withdrawn from the account at any time with no penalty or taxes to pay for qualified medical expenses.  

An HSA can be established only along with high-deductible health insurance plans that meet Internal Revenue Service rules that set the amount of the individual and family deductible.  

The amount an employee can put in an HSA is capped at the amount of his or her annual deductible of his or her health insurance policy.  Any unused funds each year remain in the account, accumulate tax-free and can be used for future medical expenses.

HEALTH REIMBURSEMENT ACCOUNTS (HRAs)

HRAs are funded by the employer and can be used by an employee as pretax dollars.  These accounts can be set up independent of any specific health plan.  Money can be used to pay for medical expenses.  HRA funds can also be carried over from year to year.  

The amount of the contributions to the HRA varies based on the employer.  The employer owns the fund and any unused amounts may or may not be transferred on termination of employment depending on the terms of the fund.  Medical spending accounts (MSAs) and flexible spending accounts (FSAs) are versions of HRAs with particular features.

It is important, regardless of what type of plan you choose, to become as familiar as possible with the plan. Read the fine print. 

If you are receiving health benefits through your employer, a good resource is your Human Resource Department. They have many of the answers about the plan the employer offers.

It is always a good idea to go directly to the source, the insurance company themselves. Most of them have designed a user-friendly website that explains many of the intricacies of the health plans. Although it may be overwhelming, take the time to peruse the site. You’ll be better informed.

Announcing Our New Patient Portal

We are very excited to announce that we now offer the opportunity to access your child's medical information via our secure Patient Portal.

Once you've completed the sign in process, you will have access to child's health history, including visit summaries, allergies, medicaltions, visit history, vital signs, immunization records, and lab reports. 

The portal also provides appointment information as wellas symptom checker and health care articles. 

To sign up, click on: Patient Portal

To read more about our portal, click on: www.spediatrics.com/portal

5 Reasons Summertime Is a Great Time for Your Child to Get a Check-Up

Written by Debra Beaulieu Volk

Summer vacation—for the kids, anyway—is finally here. With the water park calling, scheduling your child’s back-to-school or annual checkup may be the last thing on your mind, but early summer is actually the best time of year to do so.

1. Checkups catch signs of trouble early

Medically, we might not think of preventive care as being as important for children as it is for adults, but most pediatricians can share countless stories of catching problems during regular checkups that could have been far more serious if addressed much later.

Remember, pediatricians are trained to catch signs of trouble before symptoms really flare.

Even if you don’t need proof of a physical exam for your child this year and don’t have any scheduled vaccinations for a while, the American Academy of Pediatrics still recommends an annual well-child visit. Note that well visits are different from sick visits, during which just a particular problem, such as an ear infection or allergic reaction, is the focus.

Well visits are more head-to-toe in nature, covering not just a physical exam, but also a developmental, behavioral, and learning assessment. We’ll discuss in more detail all that goes into well visits in an upcoming post.

2. Pediatricians help back you up

One reason I look forward to my children’s checkups is the opportunity to have our pediatrician reinforce behaviors I want my kids to take seriously. I don’t know about you, but my children, ages 7 and 8, are more eager to impress a role model such as their doctor than they are boring old me.

So when our pediatrician engages them in a quick discussion about the importance of eating a “rainbow” of fruits and vegetables, wearing their bike helmets, reading for fun, and more, it makes those things an easier sell for me at home.

The start of summer is an excellent time for kids to hear these reminders. 

3. You can beat the rush

Additionally, our office isn’t nearly as busy in July as it will be right before school resumes, when a lot of parents are rushing to squeeze well visits in at the last minute.

Avoid the crunch by calling our office today. Save even more time (and money) by requesting to have any forms, such as for sports participation, filled out during your child’s visit. 

4. A pleasant experience is doable

We understand that some kids are not big fans of going to the doctor, which makes for a disincentive to schedule any visit that isn’t absolutely necessary. But again, once problems develop it’s too late for preventive care.

An earlier post from one of our medical assistants offers some great tips for helping children feel more at ease with the experience—and therefore less likely to put you through the wringer for bringing them.

Honestly, an annual checkup is a nice opportunity for kids to feel special and get to show off a little. My children really enjoy the attention they get from their doctor and the staff and finding out how much they’ve grown.

Shots are not their favorite, of course, but a little praise for putting up with the pinch goes a long way. 

5. It’s cost-effective

Keep in mind, however, that most insurance companies will pay for one well-visit per 12-month period. So if your child’s last checkup was in September, for example, you can’t move it earlier this year, only ratchet forward (but check with your carrier to be sure).

The good news is that thanks to the Affordable Care Act, most health plans have improved their coverage for preventive care. This means more cash leftover for all of the other summer activities on your list!

The Illinois Department of Public Health will require that students entering 12th grade must be immunized against bacterial meningitis

Beginning with the 2015-2016 school year, the Illinois Department of Public Health will require that students entering 12th grade must be immunized against bacterial meningitis.

Meningitis is an inflammation of the membranes surrounding the brain and spinal cord.  It typically affects young people under 20 year old, and those living in community settings (i.e. college dormitories.)

This disease can have several serious complications, such as : hearing loss, memory difficulties, learning disabilities, brain damage, gait problems, seizures, kidney failure, shock and even death.

Due to the serious nature of this disease,  All 12th graders will need to show proof of receiving two doses unless the first dose was administered after 16 years of age. 

Documentation of these vaccines will be required, before you can register your child in August, 2015.

Call our office, and we would be happy to schedule your child for their yearly well visit so they can receive the necessary vaccines.

For more information, visit healthychildren.org

4 sun-safety saboteurs and how to prevent them

Written by Debra Beaulieu-Volk

As parents, we sure know a lot more about sun safety than we did as kids or young adults ourselves. SPF 2 dark tanning oil, anyone?

But even though we now understand the importance of protecting our children from excessive sun exposure and have resources such as this blog and healthychildren.org at our fingertips, following this advice is sometimes easier said than done.

Here are a few sun-protection snafus I’ve experienced personally, and how your family can help prevent them:

1. Over-reliance on sunscreen. Parents don’t always think about it this way, but pediatricians will tell you that sunscreen is actually a third-line defense. Among the most effective ways to protect children from sun exposure is with clothing. While you can purchase swim shirts and other protective garments labeled with an Ultraviolet Protection Factor (UPF), any tightly woven materials generally block out more rays than lighter fabrics. In addition, remember to be most sun-cautious during peak hours of 10 a.m. and 4 p.m. If participating in outdoor activities between these hours, try to find a shady spot to work in some “sun breaks” throughout the day.

2. Overlooked exposure. Easily missed or forgotten spots to cover include tops of feet; scalps (especially hair parts); and areas covered by dry swimsuits, but notsomuch once material gets waterlogged and/or full of sand. Just being aware of these vulnerabilities is half the battle, but I find the best way to handle the shifting-swimsuit scenario is to apply one good layer of sunscreen onto kids before they get dressed, going in a couple inches more than it looks to be necessary. Eyeballs themselves are also vulnerable to sun damage, so wide-brimmed hats and sunglasses are not just fashionable, but essential.

3. Being in a rush. It may feel as though slathering squirmy children in sunscreen takes forever, but it’s really just a few moments that can contribute to kids’ lifelong health. To make sure your efforts are not in vain, use a sunscreen that says "broad-spectrum," with a sun protection factor (SPF) of at least 15 (up to 50). Sunscreen sticks can make facial application faster, but remember to blend and be more thorough than you’d think. Sunscreen should be applied 15 to 30 minutes before going outside—and reapplied every 80 minutes or sooner after swimming. Please don’t make the mistake of skipping your own sun-protection ritual to save time! It’s not just an ill-advised sacrifice, but also a poor example.

4. Not making kids accountable. Although you shouldn’t rely on young children to pack protective items or apply sunscreen themselves (despite the hilarious photo-op potential!), it’s never too early to instill sun safety into their consciousness. Just talking about all of these topics with your children and as a family can help encourage good habits. Once understanding a rule, what kid doesn’t love to correct his or her parents when it’s not followed? In this situation, hearing, “Mommy, you missed a spot!” may be a valuable reminder.

In the event your child does get sunburned, we have a tool on our website explaining when to call the office, along with how to care for minor sunburn symptoms at home.