Health Insurance Frequently Asked Questions

We've compiled a list of our most frequently asked questions about health insurance because we know it can often be confusing.

We know insurance can be confusing, and we get many questions about it at our office. Here’s a helpful list of our most frequently asked questions:

What is a deductible?

A deductible is an amount you pay for covered healthcare services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

How does the copay work?

A copay is a flat fee that you pay at the time of service each time you go to your doctor or fill a prescription. For example, if you hurt your leg and go see your doctor, or you need a refill of your asthma medicine, the amount you pay for that visit or medicine is your copay. Copay amounts are set by insurance companies, and it is illegal to waive or modify the copay amount.

What is the difference between HMO and PPO?

HMO plans generally have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums and allow for the flexibility to use providers both in and out of the network without a referral. Out-of-pocket medical costs may also run higher with a PPO plan.

What does it mean to get out of network?

Out-of-network means that a doctor or physician does not have a contract with your health insurance plan provider, which can sometimes result in higher prices. Some health plans, such as an HMO plan, will not cover care from out-of-network providers at all, except in an emergency.

What is copay vs. out-of-pocket?

Copays and deductibles are two words that represent the percentage or amount of money you’re responsible for paying as part of your health insurance coverage. Both are known as out-of-pocket expenses. A copay is a fixed amount that is paid at the time you receive medical services or get a prescription filled.

What is the difference between basic Medicare and Medicare Advantage?

Original Medicare covers inpatient hospital and skilled nursing services – Part A – and doctor visits, outpatient services, and some preventative care – Part B. Medicare Advantage plans cover all the above (Part A and Part B), and most plans also cover prescription drugs (Part D).

Can I get a yearly physical for free?

All patients, regardless of insurance type, may have a yearly preventive visit (what is often referred to as a physical) at no cost as long as the visit is restricted to preventive care only. These are the rules set by insurance companies. The doctors and PAs at NCFMG are accustomed to handling any medical issues brought forward during a physical. However, a preventive visit includes topics such as cancer screening, review of vital signs and personal and family history, a complete physical examination, administration of vaccines, and other preventive medicine topics.

Evaluation of medical problems such as ankle pain, anxiety, gastrointestinal complaints, and really any medical problem or complaint is not considered preventive care. While all providers at NCFMG expect to help our patients with their unique medical issues during a yearly physical, the insurance companies do not consider that preventive care. The result is a free preventive visit AND billing for the medical issues. Depending on your insurance type, this could result in a copay or an office visit charge that is applied to any deductible.

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We're happy to answer any questions you may have, feel free to call us at
(760) 942-0118