How to Decode Your Health Care Plan
| 3 min read
Rick Notter is vice president, Individual Business Unit, at Blue Cross Blue Shield of Michigan. He joined Blue Cross in 2011 and has over 20 years of experience in the individual insurance business. A graduate of the University of Southern Indiana, Rick began his professional career as a television anchor and reporter in Indiana. He left his TV career and founded a sports newspaper covering Indiana University basketball and football, building it to a circulation of over 20,000 with subscribers in all 50 states and 21 foreign countries. After he sold the publication, Rick began his career in the insurance industry. Rick is the author of two books, the Hoosier Handbook and Sound Advice: Music’s Effect on Life, Health and Happiness. Rick has received awards from The Associated Press, the Society of Professional Journalists, The Midwest chapter of the Radio and Television News Directors Association, The Indiana Psychological Association, The Indiana Dietic Association, Writer’s Digest, and The Next Generation Indie Book Awards. He is also a 3-time winner of the Evansville Freedom Festival Chili Cookoff. Rick currently serves on the Board of Trustees for Detroit Public Television and is a past board member of the Indiana Association of Health Underwriters, the College Sports Publishers Association, and the Monroe County (Indiana) YMCA. Rick has four children (two of whom live in Michigan) and three grandchildren. When not working, Rick enjoys spending time with his children, traveling, or playing golf.
Types of Health Plans
- HMO (Health Maintenance Organization): With an HMO, a primary care physician helps to facilitate a patient’s treatment. This includes preventive services like a routine checkup or immunizations, as well as providing referrals for specialists (i.e. a cardiologist or podiatrist). HMOs can be limited to in-network care or a specific service area.
- Medicare Advantage: During the annual election period, one can sign up, disenroll or change their Medicare Advantage (Part C) plan. Offered through private insurance, it provides hospital, medical, prescription, dental, vision and hearing coverage. There’s also an annual limit for out-of-pocket costs, meaning once you reach a certain amount, Medicare pays for 100 percent of the remaining services.
- Medicare Prescription: Medicare’s prescription drug plan (Plan D) is optional coverage that works alongside Original Medicare (Part A and B) and Medicare Advantage. Subscribers are required to pay a monthly premium, copays or a potential deductible. Like Advantage, one can enroll during the annual election period.
- PPO (Preferred Provider Organization): Unlike an HMO, this plan doesn’t rely on a primary care physician to manage one’s treatment. Referrals are not necessary to see specialists and oftentimes, members can opt for out-of-network coverage. Although, in-network care is more affordable as it requires little to no copay.
Common Health Care Terms
- Coinsurance: This is the percentage of covered health care services a patient is expected to pay after a deductible is met. If a person’s insurance plan has a 20% coinsurance, the individual is expected to pay 20% of each medical bill.
- Copayment: A copay is a fixed dollar amount the patient is expected to pay for health care services. Scheduled doctor visits typically range between $25 and $50, depending on the plan. This cost is generally paid at the time of the visit, rather than billed later.
- Deductible: The amount a patient must pay on covered health care services before an insurer starts contributing. Throughout the year, these payments go towards an annual deductible. Once the deductible is met, patients share the cost with the health insurance company by paying coinsurance and copays until the total benefit maximum is reached.
- Provider Network: A provider network is determined by a health care plan. Opting for an in-network doctor versus out-of-network can drastically affect the cost of services. Health insurance websites or mobile apps, like bcbsm.com, are great places to confirm if a current or new doctor is covered under a specific plan.
- Total Benefit Maximum: This is the total dollar amount an insurance company will pay during an individual’s lifetime for non-essential health care services. Examples include mental health and substance use treatment, maternity/newborn care and preventive services such as the flu shot.
