Insurance Explained - My Bariatric Solutions

Insurance Explained

This is the time of year where we start to worry about our insurance plan specifics as it applies to medical treatments and procedures.  Below are some terms you will hear if planning a doctor’s visit, routine colonoscopy, or imaging service.

  • Deductible: The Annual amount you pay before your plan starts to pay
  • Coinsurance: After your deductible is met, you share responsibility for payments with the insurance company, i.e. you pay 20% and the company pays 80%.
  • Out-of-pocket (OOP) max: The MAXIMUM amount you pay each year for medical service
    • Check your plan details to determine if the deductible applies to your OOP (Note: deductibles do apply).
  • Copay: A flat dollar amount you pay for a doctor’s visit.
    • Your copay could also be a Coinsurance percentage amount that you pay after your deductible is met
  • Calendar Year versus Plan Year:
    • Not all insurance plans run from January – December which is a Calendar Year Plan
    • Example: A Plan Year benefits start 9/1 and go through 8/31 to make a full year – most teachers fall under a plan year
    • Varies for every Insurance company
  • Keep in mind that not every insurance plan and company are alike.
    • Some may never pay 100% after the deductible and OOP are met
    • Some may cover at 100% after your deductible is met

When choosing an insurance plan, here is what to look for:

  • Look for plans that have Preferred Provider Organization (PPO) plan type coverage, rather than an Exclusive Provider Organization (EPO) or Health Maintenance Organizations (HMO), which have limited provider/facility coverage
    • EPO and HMO will have high OOP or no coverage for Out of Network Providers
    • PPO has both IN and OUT of network coverage typically at the same benefit level for deductible and OOP expenses
  • Tier Plans: The most common being Teachers TRS Aetna, has 3 tiers to choose from:
    • ActiveCare1- HD
    • ActiveCare2 (not available after 9/1/2018)
    • ActiveCare Select or Wholehealth
      • The ActiveCare-1- HD has the best In/Out of network coverage with Bariatric benefits.  The plan has a required $5,000 Bariatric copay that DOES apply to the OOP maximum
      • The ActiveCare-2 has Bariatric coverage, however, the $5,000 copay DOES NOT apply to the Out-Of-Pocket maximum. If you have this plan you will have to pay that on top of your OOP. Also, the second tiered plan has higher copays and deductible and OOP expenses
      • The 3rd tier: ActiveCare Select plan does NOT have any Bariatric coverage and has limited network for providers and facilities you may use for medical services. Meaning anything not in that network is NOT covered at all. It does have a lower deductible, but a higher OOP than the Tier 1 plan.