Health Insurance 101: Choosing the right plan for you.


As open enrollment is just around the corner and many of our patients are asking us our opinion on insurance plans I feel it may be helpful to explain what insurance is, what it isn’t, and how to properly choose the plan best for you. Before you read the rest, please watch this short video. It simplifies what insurance is supposed to be and what it is not supposed to be.(Disclaimer: All views expressed in this video may not be held by Tri-Lakes Family Care. It does help educate all on how insurance is structured.)

So let’s start with the basics. First we will explain what the confusing terms that insurance companies use mean so you can have a better idea of what to look for when you are choosing your plan.

  1. Premium: This is the amount you have to pay per month to have active insurance coverage. This can be either individual cost or a family plan.
  2. Co-Pay: This is the amount you pay up front when going to see a health care provider. Typical co-pays for primary care range from $20-35 dollars while co-pays for urgent care are sometimes $50-75 per visit. THIS DOES NOT MEAN YOU ONLY PAY THIS AMOUNT TOTAL FOR THE VISIT. It simply means this is what you pay up front when you need an appointment.
  3. Co-Insurance: This is the percentage you pay for covered services until you have reached your max out of pocket limit. Most of the time this is either 20% or 30% of the cost. You’ll often see this listed as an 80/20 plan or a 70/30 plan. Meaning, if you have a medical bill for $100 then your 80/20 plan will pay 80% of the cost while you get billed for the 20% meaning you will pay $20 of the bill.
  4. Deductible: This is what you are required to pay before your insurance will pay on your behalf. So if your deductible is $5000 then you will pay up to $5000 until your insurance will start paying anything on your behalf.
  5. Max Out of Pocket Cost/Out of Pocket Limit: This the maximum you will pay for health care services in a year. THIS DOES NOT COUNT YOUR PREMIUM.It does count your copays, deductible and coinsurance costs.So here’s an example of a plan that people often choose and how it would work in real life. Often individuals will purchase an 80/20 plan with a $200 monthly premium, $20 copays for PCP visits and $50 copays for urgent care, having  a $6,000 deductible and a $7,000 max out of pocket cost. This means when you go to your health care provider with a sinus infection you would pay either $20 for seeing a PCP or $50 for seeing someone at urgent care up front on the day you are in their office. Then, if you have not used your insurance at all that year yet, the $120 bill that the health care provider files with your insurance will now be your full responsibility making your total cost for a sinus infection be $140 or up to $170 for urgent care. If you had a car accident and you had paid $6,000 in medical bills to the Emergency Department and then had the same sinus infection then your 80/20% plan would kick in and you would owe an additional $20 at the end of the day until you paid  a max of $7,000 out of pocket that year.

So as you can see just the terms can be overwhelming, much less choosing a full plan. Here’s some nuts and bolts to remember:

  1. If you love your current health care provider and want to stay their patient the FIRST thing I would do is call and find out what insurance plans they have a contract with. This way you don’t pick a plan and then find out that you cannot keep going to your current provider. As a provider we cannot always get contracts with insurance companies even if we want to. For example, currently we would LOVE to accept Cox Health Plans. However after two attempts they have not accepted us into their network. So our patients who carry Cox health plans have to go out of network when they see us.
  2. Most of the time if your monthly premium is LOW then your Out of Pocket Limit and Deductible will be HIGH. Alternatively, higher premiums result in less out of pocket costs when something goes wrong.
  3. If you rarely use a health care provider then it would likely be wise to go with a high deductible plan and therefore save on your monthly premium. Although the risk with this is that if something does go wrong and you end up with a high out of pocket cost you must pay for choosing the lower premium plan.
  4. Look into OTHER options for insurance. For instance there are companies like Christian Health Care Ministries, Medishare, or Liberty Health share. They are ACA exempt so you will not be fined for not having insurance and are so affordable.

I’ll share my personal experience. My family of four who are all healthy and have no previous medical problems applied for insurance. The lowest option we could find was for a premium of $898 per month, with primary care copays of $30, Urgent Care copays of $75, and our deductible was $12,0000. I don’t even remember what our max out of pocket cost was because I was so blown away at the almost $900 monthly premium for a horrible $12,0000 deductible! We decided to become members of Medishare. We now pay $205 per month and our deductible as a family is $5,000. (PS I do not get paid for my blogs, so I am simply sharing my experience. I am not a salesman)

Finally, as health care providers we understand that insurance is a tough hoop to jump through. If you have questions ask your health care provider. If they don’t have the right answer it is likely they will know an expert for you to reach out to.

We at Tri-Lakes Family Care currently accept the following insurances: Anthem Blue Cross Blue Shield, Coventry, United Health Care, Health Link, Cigna, Multiplan, Medicare, Medishare, & Medicaid(and maybe even more that I might have forgotten to list). Our current self pay rates are extremely affordable with the first visit being $100, and every visit after is $85. We often can offer ultrasounds for a rates between $80-$120, and labs are often under $100 for yearly panels that include sugar, cholesterol, liver function, kidney function and thyroid function. So if you are cash pay and need someone to consult with regarding your health we would be glad to help you and hopefully save you money.

Feel free to message us with questions through our website. If we don’t know the answer we will find someone that does!

As always, I hope you stay happy and healthy,

Carolyn Clark, NP-C