It’s a New Year! Take Control of Your Healthcare in 2025 by Understanding Your Coverage and Benefits
As the new year begins, many of us review our health insurance coverage to make sure we’re taking full advantage of the benefits available to us. If you have new insurance or your plan has changed, it’s important to understand how it applies to your family medicine care. Knowing how to navigate your insurance plan can save you time, money, and stress throughout the year.
Here are some key points to consider when reviewing your insurance coverage as it applies to visits to your primary care physician (PCP):
1. Choosing the Correct Primary Care Physician (PCP)
Your health insurance plan often requires you to choose a PCP from their network. This is especially important if you have a Health Maintenance Organization (HMO) or a similar plan that limits care to specific providers. Check your insurance to make sure you have selected the correct PCP, as visiting an out-of-network doctor could result in higher out-of-pocket costs or even a complete denial of coverage.
2. Understanding Your Copay/Coinsurance
Most insurance plans have a set copay (a fixed amount you pay for each visit) for primary care visits. It’s important to know what your copay is for family medicine office visits, as this will be the amount you’re responsible for paying at the time of your appointment. If you’re unsure about your copay, you can check your insurance card or contact your insurance company for clarification. If your insurance charges you a coinsurance, that is a percentage of the cost of your visit that will be due after the claim is finalized and posted, most likely by the time of your next visit.
3. In-Network vs. Out-of-Network Providers
When you visit a healthcare provider, it’s important to know whether they are in-network or out-of-network for your plan. In-network providers have an agreement with your insurance company to provide services at lower rates, and typically, your insurance will cover a larger portion of the cost. Out-of-network providers, however, may result in higher out-of-pocket expenses or may not be covered at all unless you have a PPO plan.
This rule can apply not only to doctors and hospitals, but to labs, imaging, pharmacies, home healthcare, and many more types of medical providers as well. For example, if you are insured by Simply Healthcare HMO, Clear Health Alliance, or Freedom Healthcare, you will not be able to use Quest Diagnostics for your labs so it’s best to ask the provider to send your order to LabCorp.
Make sure your family medicine provider is listed as in-network with your insurance. If you’re unsure, you can contact us or check directly with your insurance provider.
4. Does Your Plan Have a Deductible?
A deductible is the amount you must pay out of pocket for healthcare services before your insurance starts to pay. Some plans require you to meet your deductible before insurance covers most services, while others may have a lower deductible for certain services, like primary care visits.
If your deductible has not been met, then you may need to pay up-front for your visit. In this case, Best Care Family and Wellness Centers will charge you our self-pay rate for any covered services until your deductible is met. (If your insurance pays us despite an unmet deductible, don’t worry! We will refund or credit you for any overpayments once your insurance processes the claim.)
5. Reaching Out for Help
Navigating insurance can be complex, but you don’t have to do it alone. If you have questions about your insurance benefits or need clarification on what’s covered, you can contact your insurance company’s customer service. Additionally, our office is here to help guide you and answer any questions about your coverage as it pertains to visits with us.
Taking the time to understand your health insurance plan ensures that you can make the most of your benefits and avoid unexpected charges. If you’re unsure about any part of your coverage, we encourage you to reach out to us or your insurance company for assistance. By staying informed, you can take control of your healthcare this year and beyond.
If you have any questions, please don’t hesitate to call our office. For questions regarding your coverage or whether we accept your insurance, just call the front desk to your nearest Best Care clinic location. For questions about a specific claim or charge from our clinic, please contact billing@bestcarefaimly.com with all the relevant details and your contact information. We’re here to help!