Captain Health USA

Making Health Insurance Great Again!

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EOBs – What You Need to know!

What is an EOB?

The shortest answer is that it is NOT a bill.  Instead, it is an Explanation Of Benefits. It shows exactly what was covered and who is paying what.  

When To Expect an EOB

EOBs are usually sent every time you see a health insurance provider.  That means each time you visit your:

  • Primary care physician
  • Dentist
  • Specialists


7 Things You Will Find On Your EOB:

  1. Service Description – A description of the services you received during your visit
    2. Provider Charges – These are the fees that you provider bills for your visit
    3. Allowed Charges – This is the amount that your provider will be reimbursed
    4. Paid By Insurer – how much your insurance plan pays the provider
    5. Payee – this is the person who will receive reimbursement for over-paying the claim
    6. Insured’s Costs – The costs you are responsible for
    7. Remark Code – explanation of costs provided by the insurance plan


Not sure where to find all of this information?  Many insurance providers will have samples of their EOB statements that you can refer to so that you understand each section of the document.   The majority of health insurance companies provide online access to EOBs. Contact your health insurance company and ask how you can get internet access to your EOB files.   It’s a good idea for you to get familiar with the EOB statement provided by your insurance company. It will help you from overpaying providers you see for medical treatment.  It can also help you spot errors in any bills you may receive. Let’s face it, mistakes happen – billing codes can be entered incorrectly, system glitches occur, items can be overlooked.  


Final thoughts…an EOB can be your BFF when it comes to making sure your medical bills are handled correctly.  After all, YOU are in charge of your healthcare which means you have rights – especially fair billing. Take the time to review your EOB and learn how to read it.  If you have questions, call the customer service department of your insurance company to get the answers you need so that you can make informed decisions and be proactive when needed.


Do you have questions about your current health care coverage?  Reach out! I can help!  (813) 391-3448


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What You Should Know About Staying in Network

There are lots of reasons why you should stay in-network when seeking medical care.  But, too truly understand the reasons, you must first understand what a health insurance network is.  Once that piece is in place for you, the rest will make much more sense.


When a doctor is considered in-network, it means that he or she has contracted with your insurance company to provide medical care to their members.  Because of this contract, it usually means you end up paying less for health care services provided by that physician. Should you see a doctor who has not contracted with your insurance provider, that visit and physician would be considered “out of network” and could cost you quite a bit more money.  It is important to note that the terms “in network” and “out of network” also pertain to lab work, pharmacies, specialists, etc.


Let’s dive in and explore some areas you should be aware of when it comes to health insurance and staying in-network.


How to Find In-Network Providers

Insurance companies usually have an online directory that you can use to find which doctors are in their network.  If you don’t remember getting a directory or you lost the link, I have a handy tool you can use to find doctors in your network.  To gain access click HERE.


Why Would You Go Out Of Network?

There are many reasons you may need to go out of network.  Here are just a few:

  • Life doesn’t always go as planned.  Medical emergencies may require you to get immediate attention outside of the network.
  • In some cases, your primary or treating doctor may want to refer a specialist. Sometimes that specialist may not be included in your network. If that’s the case, do your research.  Make sure the specialist you are being referred to is truly the best resource for your circumstances. In some cases, you may be able to speak to your insurance company about getting out of network care at in-network pricing.
  • Changing providers would jeopardize your health.
  • Proximity to adequate care. The ACA requires insurers to maintain provider networks that are within a reasonable distance and time to the member.
  • Natural disasters forcing members to evacuate to areas outside of their network.  In these cases, some insurers will extend in-network pricing.


What Happens If Your Get Hurt or Sick When Traveling Domestically?

This is a really good question!  At some level, all plans have some sort of out-of-state coverage when it comes to emergencies.  Unfortunately, there isn’t a clear definition of what an emergency is. What may seem like an emergency to you may not be considered an emergency by your insurance company.  Before you go on your trip, make sure you understand what your specific plan covers when you travel and what is considered an emergency versus what is not.


Making Sure You Are Covered When You Travel

If you travel frequently or reside in different states throughout the year, you may want to consider opting into supplemental coverage.  Supplemental coverage is a policy you purchase to help pay for things like services and out-of-pocket expenses that your regular insurance does not cover. Some supplemental insurance plans will pay for out-of-pocket medical expenses, such as deductibles, copayments, and coinsurance.  When looking into supplemental health insurance, make sure you do your homework. Determine whether the coverage will be sufficient when you travel out of state.


Final Thoughts:

Always take the time to determine whether or not the doctor, pharmacy, lab, etc. is in your network or not.  This one detail can mean the difference between a copay and a huge medical bill.

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Limited Balanced Billing, A New Law, And What It Means For You…

Balanced Billing.  This is a term you are going to want to get to know!  In a nutshell, balanced billing is when your provider has the opportunity to bill you for an outstanding balance after your insurance company has covered its portion of medical expenses.  What this also means is that out-of-network doctors who are not bound by in-network negotiated rate agreements can bill patients for the entire remaining balance not covered by insurance.  These bills can be hefty to say the least! That’s where the new law surrounding limited balanced billing comes into play.  

Limited Balanced Billing refers to a monetary cap that is put on remaining balances not covered by insurance.  The new law states that patients cannot be charged more than the equivalent of in-network fees.


  • Let’s say you needed a certain procedure done and due to certain circumstances, the procedure had to be done out-of-network.  
  • The out-of-network fee was $20,000 but the in-network fee was only $5,000.
  • Under this new law, after insurance has paid its portion, the out-of-network physician can only charge you an additional $5,000 since that is what the in-network fee is for the exact procedure you had done.

One other very important part of the law concerns out of network provider charges when you are in a hospital or a facility of some kind.  Say you have a procedure done at an IN NETWORK facility and the facility uses some one that was out of network.  In the past you could be billed for the out of network providers fee.  Due to this law you may not have to pay that fee.  It is very important  to specify to everyone  that you want only in network providers.  I like to write it on the paper when I sign for the procedure.   I write “in network providers only”. This way you have some proof of your wishes. In addition, I also take a picture of the paper I signed so I can use that as proof.  Just so my lawyer friends don’t yell at me…..I’m not giving legal advice here, I’m just saying what I do.

When receiving medical bills, it is important to scrutinize your bill and understand what you are being charged for and what is considered in-network versus out-of-network.  Compare these charges to your medical plan coverage to make sure you are being charged fairly. If you have questions about your bill, advocate for yourself. Call your insurance company and get your questions answered.

Do you have questions about health insurance, your coverage, and how to get the most out of your plan?  Let’s chat…I can help! (813) 391-3448

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Pre-Open Enrollment Checklist

It’s almost THAT time of year!  That’s right, open enrollment is right around the corner.  Depending on how you plan for the event, will determine how smooth or not so smooth the process will be for you and your family.  

Upcoming Open Enrollment Dates:

Make sure these dates are on your calendars…

Thursday, November 1, 2018, to Saturday, December 15, 2018.  Please keep in mind that if you already have coverage you will be automatically renewed.  We would just need to update any family, address, or income changes.

Note:  If you don’t act by December 15, you can’t get 2019 coverage unless you qualify for a Special Enrollment Period.

Plans sold during Open Enrollment start January 1, 2019.

If you need new coverage…..Checklist

  • Household size:  Make a list of the people in your household that will be needing health Information (see below for a snapshot of who should be getting or qualifies for health insurance)
  • Home and/or mailing addresses for everyone applying for coverage.
  • Information about everyone applying for coverage, like addresses and birth dates.
    Social Security Numbers.
  • Document information for legal immigrants. 
  • Information on how you file your taxes.
  • Your best estimate of what your household income will be in 2018. 
    for help estimating your income.

Here’s a quick snapshot of who qualifies for health insurance coverage in your home:

  • Dependent children, including adopted and foster children
  • Children – shared custody (only those who you claim as dependents during the tax year)
  • Non-dependent child under 26 – only if you want to include them on your policy
  • Children under 21 you take care of and who lives with you, even if not your tax dependent.
  • Dependent parents only if you claim them as tax dependents
  • Dependent siblings and other relatives only if you claim them as tax dependents
  • Legally married spouse

After you have gathered all of the information listed above, call a health insurance agent who is well versed in the Affordable Care Act and understands the laws that surround it.  You will want to have discussions about things like:

  • The 4 “metal” categories and what they mean for you and your family
  • Understanding how much your monthly health insurance will be
  • A clear explanation of the plans and the networks available to you (HMO, PPO, POS, EPO)

If you do not have an agent and need help in making the best healthcare coverage decisions for you and your family, I am here to help!  Schedule your FREE consultation by calling: (813) 391-3448

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Open Enrollment is Right Around the Corner… Will you be ready?

Don’t let this year be the year you are scrambling to get things in order for open enrollment.  Use my Open Enrollment Guide below to help you through the process so that getting the right health care coverage doesn’t become a huge ordeal.  


Key Dates You Need To Be Aware Of Before Open Enrollment Begins:

  • The 2019 Open Enrollment Period: November 1, 2018, to December 15, 2018.
  • Plans sold during Open Enrollment start January 1, 2019.
  • If you don’t act by December 15, you can’t get 2019 coverage unless you qualify for a Special Enrollment Period.


Pre-Open Enrollment Checklist:

  • Household size:  Make a list of the people in your household that will be needing health insurance during 2018
  • Current mailing address for everyone who is applying for coverage
  • Birth dates for all household members
  • Social security numbers for everyone who will be getting coverage
  • Information about how you file your taxes
  • Estimate of what your household income will be for 2019
  • A list of any major life changes for each member of your household getting coverage such as  Marriage, Income, Moving, Births, Divorce, etc.


Understanding Special Enrollment Period (SEP)

Special Enrollment Period is a time outside of the yearly Open Enrollment Period that allows you to sign up for health insurance. The following circumstances qualify you for the special enrollment period (SEP):

  • Losing health coverage,
  • Moving,
  • Getting married,
  • Having a baby,
  • Adopting a child.


Did You Know? If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a health insurance plan. If you miss that time period, you will have to wait until the next open enrollment period to get on a health insurance plan.

Medicaid & CHIP:  You can enroll in Medicaid and the Children’s Health Insurance Plan (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not.

Job-based Plans:  These plans must provide a special enrollment period of at least 30 days if you are losing coverage due to changing jobs.


Tax Penalties:

These penalties will be going away.  If you do not enroll in a health insurance plan, you will no longer face fines or penalties for not carrying coverage.  However, that does not mean you will be fully treated anymore.  A hospital only has to stabilize you but they do not have to actually repair you or do follow on services.   As an example, they can treat the broken arm to stabilize it but they do not have to do the surgery to repair it like new unless you can show you have insurance or that you can pay for it another way..


Next Steps:

Now that you have a snapshot guide of what to expect during open enrollment for 2019, schedule time to speak with me so we can select the best plan possible for you, your family, and your situation.  A year without proper medical coverage could result in medical bills and expenses you weren’t expecting. Did you know medical debt is the leading cause of bankruptcy in the United States? This can be avoided if you have the proper coverage and plan in place.  I am here to help! Schedule your FREE consultation by calling: (813) 391-3448

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The Importance of Keeping High Blood Pressure Under Control

You’ve been diagnosed with high blood pressure, now you’re wondering what the risk is and what you should be aware of with this new diagnosis.  High blood pressure isn’t something to ignore. In fact, you should be vigilant about keeping it under control and at a safe level. Below is a list of 7 things that can happen as a result of high blood pressure if left untreated.


Bone Loss

Those with high blood pressure or hypertension tend to excrete more calcium through their urine resulting in low bone density leaving them susceptible to bone breakage and poor dental health.


Sleep Issues Relating to OSA

Those who are overweight and snore due to obstructive sleep apnoea tend to also have high blood pressure.  


Sexual Dysfunction

High blood pressure can result in sexual dysfunction in both men and women.  Men can experience erectile dysfunction and women will experience vaginal dryness.  Both men and women can experience low sex drive as a result of high blood pressure.


Kidney Failure

When arteries and blood vessels narrow and harden due to high blood pressure, it reduces flow to the kidneys making them unable to function properly.  Without proper blood flow, the kidneys are unable to flush toxins out of the body and remove excess water. The inability to function properly will result in kidney failure.


Artery Damage

Sustained high blood pressure causes extra force on the artery walls.  This exertion on the artery walls can cause damage to your arteries making them susceptible to plaque which can both harden and narrow the arteries.  When this hardening occurs, blood flow to organs in the body can be interrupted.


Damage to Eyes

When blood pressure is uncontrolled, it can cause damage to the eyes by causing the blood vessels in the eyes to thicken and narrow resulting in reduced delivery of oxygen to the retina.  The result can be bleeding in the eyes caused by burst retinal veins. If left untreated, hypertensive retinopathy can result which can lead to blindness.


Damaged Brain Cells

Blood clots can develop in arteries as a result of high blood pressure causing a decrease in oxygen in the brain.  This causes brain cells to die resulting in dementia or stroke.


Risk of Stroke

If you are able to lower your blood pressure, you are also lowering your risk of stroke.  If left untreated, high blood pressure can weaken the blood vessels found in your brain causing them to leak, rupture or both.  Additionally, high blood pressure can cause blood clots in your arteries which can block blood from being delivered to the brain which can also cause a stroke or even dementia.


Now that you know what can happen if you don’t keep your blood pressure under control, it’s time to do something about it.  There are some things you can do right away to start making a difference in your blood pressure and your overall health. Check out our list below.

8 ways you can naturally keep your blood pressure under control:

  1. Drop excess weight
  2. Exercise regularly
  3. Eat a healthy diet
  4. Reduce salt
  5. Limit alcohol consumption
  6. Quit smoking
  7. Reduce caffeine intake
  8. Reduce stress


Final Thoughts…

Should you be diagnosed with high blood pressure or hypertension, it is imperative for you to be under a doctor’s care.  They will closely monitor you and make suggestions of how you can control your blood pressure. In some cases blood pressure will be treated with medication while in others, blood pressure can be controlled with lifestyle changes.  Your doctor or cardiologist will advise you of what is best for your individual diagnosis.

To your continued health!

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What Is The Real Cost of NOT Having Health Insurance?

By now we all know the ramifications of not having health insurance during 2018, especially when tax season comes around.  For the 2018 tax year, the penalty for not having health insurance is $695 per adult or 2.5 percent of household income, whichever is greater.  That’s a hard pill to swallow (no pun intended). But, is the tax penalty the only penalty you or your family will pay for not having health insurance?


Without having health insurance available to you and your family can be a costly oversight.  Let’s say, during the summer, one of your kids break their arm. What would be the total cost to you, with or without insurance?


With Insurance:

Typical non-surgical initial treatment for a broken bone: $2,500

Let’s say your deductible was $1,000, you would be responsible for that amount plus any copay amounts your plan requires per doctor visit, treatment requirements, x-rays,  or follow-up appointments.


Without Insurance:

Typical non-surgical initial treatment for a broken bone: $2,500

Without insurance, you would be responsible for paying for the initial treatment as well as items such as:

  • Doctor visits/follow up visits: $250 per visit
  • X-Rays: $1,000
  • Cast/Splint Application: $239

Suddenly, the $2,500 initial treatment for the broken bone jumped to a total of $3,989…and that’s on the conservative side.  


What if the medical attention you needed was more critical?  What if you had an acute onset of appendicitis? What would your medical bills look like then?  


Using the same scenario of insurance with a $1,000 deductible you can expect your appendectomy to cost anywhere between $10 – 35,000.  Again, you would be responsible for your deductible of $1,000 and any copays following the procedure.


Without insurance, you can expect to pay anywhere from $10 – 35,000 or more depending on how the procedure is done.  The price for the procedure can jump depending on things like the type of procedure performed if there were complications, and length of hospital stay.  With so many variables, it is hard to pinpoint what the total cost would be. But, just to give you a ballpark amount, the national average for an appendectomy is $13,199 according to


No one can predict the future.  Unfortunate and unexpected accidents happen all the time.  Without the proper measures and insurance in place, you could place yourself into a huge hole of medical debt.  Don’t risk your financial health and your well-being.  Take the time to explore your health insurance options and get the coverage that works best for you and your family.  The open enrollment period for 2019 is not too far away. It begins November 1, 2018. Now is the perfect time to get prepared.  I can help answer any questions you may have about things like:

  • Affordable health insurance options
  • Subsidies and how you can apply for them
  • What your deductible will look like should you need to use your health insurance
  • The best insurance plan for you and your family


Once you truly understand the risks involved in not having coverage and how the benefits of health insurance outweigh the risks, you will have peace of mind.  Contact me today to discuss your options: (813) 391-3448