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6 Things To Know Before Selecting Or Changing Your Health Coverage
Enrolling in health insurance
gettyFor many employees, open enrollment for benefits selection occurs between October and November. Selecting from a long list of choices can be overwhelming to say the least.
If you are switching health coverage, it's important to understand your deductible, the maximum out of pocket, the implications of in-network and out-of-network care, and what it would cost you to maintain your existing healthcare routine. Two common categories of health coverage I see are Health Maintenance Organizations and Preferred Provider Organizations. Understanding the difference HMOs and PPOs can help you make an informed decision when choosing your coverage. Here are six financial considerations when deciding between these common plans.
HMOsHMOs tend to be the most inexpensive options available. Often, those with an HMO can have a great experience if they just go to a primary care doctor annually for a physical, have maybe a medication or two, and don't experience health issues. If you require a specialist, you will need a referral from your primary care physician. Usually, that specialist would be part of the same organization, which could limit your options. HMOs also usually do not cover out-of-network care at all except in the case of an emergency.
PPOsPPOs are usually well suited to people who have a preferred doctor or want flexibility in choosing a location or specialist. You also usually do not require a referral to see a specialist, allowing you to pick the best one available. PPOs tend to have wider networks and may even have a high level of coverage if you choose to see an out-of-network doctor.
CopaysCopays are most often associated with HMOs, though they can be applicable to PPOs. Short for copayments, they are set dollar amounts that you pay for specific services, like doctor visits, medications, and other in-network covered services. They are negotiated by the provider and tend not to count toward your deductible, which will be discussed later. An example would be a $25 charge for getting lab work done.
DeductiblesThe deductible you choose can greatly impact your health insurance and care costs. Plans are broadly categorized into high-deductible and low-deductible plans. Your deductible is the amount of money you must pay out of pocket before insurance starts covering services. Because of this, high-deductible plans are cheaper than low-deductible plans. With a high-deductible plan, as an example, you may need to pay for your medical costs up to $2,000 before insurance starts paying.
CoinsuranceCoinsurance is basically a percentage cost share between you and your provider. A common coinsurance amount is 80% of the cost is absorbed by the insurer, while you pay 20% of the cost. Once you've hit your deductible in a plan, there may be an applicable coinsurance amount for every cost above the deductible up to a maximum. Let's say you have a plan with a $1,000 deductible and you've incurred medical expenses of $2,000 (no other expenses this year). You would pay the first $1,000, then your coinsurance would kick in and your insurer may cover 80% or $800 of the remaining $1,000.
Maximum Out Of PocketThe maximum that you could possibly pay for covered services is known as the maximum out of pocket. It puts an upper limit on the dollar amount you're responsible for to avoid financial ruin in the case of a major medical issue. As you may guess, plans with a low MOOP will be more expensive than plans with a high MOOP because you would need to pay a smaller amount before your insurer begins paying 100% of costs.
Words Of CautionOnce you have a health insurance policy, make sure you verify with your carrier what your costs would be prior to receiving the service. Some websites may indicate that a medical provider will take your insurance but that doesn't necessarily mean the service is covered or in-network. Oftentimes, out-of-network services will count toward neither your deductible nor your MOOP, potentially causing your costs for the year to exceed the MOOP.
Varying ages and number dependents are considerations in selecting health insurance coverage.
getty Which Plans Make Sense For Different Types Of People?The plans that will cause you to pay the least money out of pocket for services will be the most expensive. So, many people don't end up with the very top of the line plans because of budgetary restrictions.
Often, I see younger individuals with a history of good health opting for a high-deductible PPO plan or HMO to reduce costs. They then supplement that plan with a Health Savings Account to cover surprise expenses when they do need care.
On the other side, I often see families and individuals with an increased need for medical care or flexibility opting for a low-deductible PPO or HMO. Usually, these plans would also be accompanied by a low MOOP, protecting families and people with high medical needs from large health care costs.
ConclusionThere are many considerations in selecting the most appropriate health coverage for yourself. It's important to weigh your personal needs against the amount of risk you'd like your insurer to assume. Communicating with the individual insurers, though a time-consuming process, can provide some clarity and allow you to plan your expenses accordingly.
This informational and educational article does not offer or constitute, and should not be relied upon, as tax or financial advice. Your unique needs, goals and circumstances require the individualized attention of your own tax and financial professionals whose advice and services will prevail over any information provided in this article. Equitable Advisors, LLC and its associates and affiliates do not provide tax or legal advice or services. Equitable Advisors, LLC (Equitable Financial Advisors in MI and TN) and its affiliates do not endorse, approve or make any representations as to the accuracy, completeness or appropriateness of any part of any content linked to from this article.
Cicely Jones (CA Insurance Lic. #:0K81625) offers securities through Equitable Advisors, LLC (NY, NY 212-314-4600), member FINRA, SIPC (Equitable Financial Advisors in MI & TN) and offers annuity and insurance products through Equitable Network, LLC, which conducts business in California as Equitable Network Insurance Agency of California, LLC). Financial Professionals may transact business and/or respond to inquiries only in state(s) in which they are properly qualified. Any compensation that Ms. Jones may receive for the publication of this article is earned separate from, and entirely outside of her capacities with, Equitable Advisors, LLC and Equitable Network, LLC (Equitable Network Insurance Agency of California, LLC). AGE-5856981.1(10/23)(exp.10/25)
Primary Care Follow-Up After Emergency Surgery Tied To Fewer Readmissions
Among patients hospitalized for an emergency general surgery (EGS) condition, primary care follow-up within 30 days of discharge was associated with a significant reduction in readmission rates, according to a retrospective cohort study of Medicare beneficiaries.
Adjusted odds of a 30-day readmission were 67% lower for patients who had a primary care follow-up within 30 days of discharge compared with those who did not (adjusted OR 0.33, 95% CI 0.31-0.36), reported Rachel Kelz, MD, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues.
"This finding highlights the potential role of PCP [primary care physician] follow-up in the early identification and management of complications and the prevention of progression of disease to a level of severity requiring readmission," Kelz and colleagues wrote in JAMA Surgery.
Patients who were treated operatively during their initial EGS visit had 79% reduced odds of readmission with a follow-up visit (adjusted OR 0.21, 95% CI 0.18-0.25), and those treated nonoperatively had 64% reduced odds (adjusted OR 0.36, 95% CI 0.34-0.39), compared with patients without a follow-up.
Postoperative care used to mean longer stays in the hospital, Kelz told MedPage Today. "And now we're really down to days -- if days -- that people stay in the hospital. So that post-discharge care space really deserves a lot of attention, and our primary care colleagues are really, quite frankly, the champions of a lot of care delivered in that domain."
Among patients undergoing EGS, 8.1% have an unplanned readmission -- and older adults experience the highest rates of readmission. Though primary care follow-up has been linked to lower readmission rates after hospitalization for other medical conditions and high-risk surgery, the implications with EGS conditions have remained unclear.
Primary care providers can help flag and treat postoperative complications like infection before they progress, or help patients make adjustments to medications, Kelz explained, preventing what could otherwise become an emergency.
She said the findings further highlight the importance of coordination of care in preventing hospital readmissions, and the role advanced practice practitioners could play in delivering care to communities where access is scarce.
"We now have incredibly well-trained allied health providers, so nurse practitioners and physician associates, and in many cases experienced nurses, who can provide a lot of primary care, and we're not encouraging their opportunity to practice across the full scope of their training," Kelz noted.
She also underscored the potential for remote care and telehealth to boost access to primary care for older adults, as did Yuman Fong, MD, of the City of Hope Medical Center in Duarte, California, in an invited commentary.
"Already, sensors are being tested and used in many health plans to take care of patients with heart failure and pulmonary failure at home to prevent hospital admissions," Fong wrote, adding that it's likely that perioperative primary care specialists will "evolve to become our partnered remote medicine colleagues to deliver superb care for surgical patients in the 21st century."
For this study, Kelz and colleagues used data from the CMS Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files between September 2016 and November 2018.
They included 345,360 Medicare fee-for-service beneficiaries ages 66 and older admitted through the emergency department with a primary diagnosis of a general abdominal, colorectal, hepatopancreatobiliary, intestinal obstruction, hernia, and upper gastrointestinal EGS condition, who received a general surgery consultation during the admission.
Patients without continuous Medicare Part A and Part B coverage, those enrolled in a health maintenance organization during the year before and the 30 days after the EGS admission, and patients who died in-hospital during admission were excluded.
Of the included patients, mean age was 74.4, 54.4% was women, and 83.9% were white; 45.4% had a primary care follow-up within 30 days after discharge. Black patients, patients with dual Medicare-Medicaid eligibility, and patients with three or more comorbidities were less likely to have a follow-up.
Overall, 17.5% of Medicare beneficiaries hospitalized for an EGS condition were readmitted within 30 days after discharge. The most common readmission diagnosis for the operative group was infection after a procedure, and sepsis for the nonoperative group.
Study limitations included the inability to identify severity and management of comorbidities, a lack of detailed clinical data not fully capturing the relationship between surgical complications and 30-day readmissions, and unmeasured confounders, including the possibility that healthier patients may be more likely to seek a primary care follow-up earlier, which Kelz and team tried to take into consideration.
The study also had a short time frame that may not have captured other visits that mitigated readmission, and did not look at the potential implications of telehealth appointments.
Sophie Putka is an enterprise and investigative writer for MedPage Today. Her work has appeared in the Wall Street Journal, Discover, Business Insider, Inverse, Cannabis Wire, and more. She joined MedPage Today in August of 2021. Follow
Disclosures
Study funding came from the NIH.
Kelz and two co-authors reported receiving grants from the NIH during the conduct of the study. Another co-author reported receiving a grant from the Leonard Davis Institute of Health Economics.
Fong reported receiving advisory fees from Medtronic, Vergent, Theromics, Iovance, and Eureka Biologics, and royalties from Imugene and Merck.
Primary Source
JAMA Surgery
Source Reference: Moneme AN, et al "Primary care physician follow-up and 30-day readmission after emergency general surgery admissions" JAMA Surg 2023; DOI: 10.1001/jamasurg.2023.4534.
Secondary Source
JAMA Surgery
Source Reference: Fong Y "Importance of postoperative follow-up for patient outcome" JAMA Surg 2023; DOI: 10.1001/jamasurg.2023.4535.
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Specialty Physicians Homewood Clinic Open House
Specialty Physicians of Illinois, LLC, the multispecialty physician group based in Chicago's Southland, will present a free Open House event at its Homewood primary care clinic on Thursday, November 9, from 1:00 p.M. To 6:30 pm.
At the open house event, visitors will have the opportunity meet board-certified family medicine physician Crystal Hines-Mays, MD, and family medicine nurse practitioner Larina Branch, FNP-BC, as well as tour the clinic and enjoy light refreshments. The Homewood clinical team will also offer free blood pressure, blood glucose and body mass index screenings.
"Establishing a relationship with a primary care physician is essential in ensuring patients receive everything they need regarding their healthcare concerns," Dr. Hines-Mays said. "Our job is to listen to patients, perform thorough examinations and prescribe medications to help treat their medical conditions. Primary care doctors also address preventative health care testing, update vaccinations and refer patients to specialists as needed."
The Specialty Physicians Homewood primary care clinic is located at 18636 Dixie Highway.
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