Captain Health USA

Making Health Insurance Great Again!

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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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When Should You Go to the ER? And, If You Do, Will You Be Stuck With the Bill?

You are experiencing excruciating pain in your abdomen.  You know there is something really wrong. Your first instinct is to rush to the hospital, it could be appendicitis but you are not sure.  It’s best to let the experts tend to you, right?  After all, they are doctors and you aren’t.  

The above scenario seems logical right?  

But it may not seem like the best course of action according to your insurance company.  

In the article titled: “An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay” (link) describes a similar story and the insurance company didn’t agree that the symptoms, the pain and the final diagnosis weren’t severe enough to warrant an emergency room visit.  In fact, the insurance company deemed the ER visit in appropriate and denied the claim which caused the hospital to demand payment for treatment and tests.  In some cases, insurance companies have begun charging their clients with “penalty fees” for inappropriate ER visits. While some of the more draconian rules have not come to Florida yet, they are in other states and the number of states is growing.  The article suggests: “All of these policies suggest a new and controversial strategy for reining in health care costs: asking patients to play a larger role in assessing their own medical condition — or pay a steep price.”  It is unreasonable to expect patients to self-diagnose and do it accurately.  

What is being done about insurance companies denying emergency room claims?  Congress is getting involved and asking questions.  Specifically, the articles sites that Claire McCaskill (D-MO) sent Anthem a letter stating, her concerns that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events.  Emergency room physicians are also taking a stand.  They are exploring options that allow them to push back to insurance companies like Anthem who have ER policies in place like the one explained here. It doesn’t stop there.  Hospitals are engaging with patient advocacy groups, asking pertinent questions, pressuring legislators to take notice of what is happening in the system and demanding better solutions.

Review your policy to make sure you understand what your policies emergency room coverage is.  If you are unsure what your policy states, get in touch with the insurance company so they can go over it with you.   If you have any questions on it please reach out to me anytime.

To read the entire article referenced in this blog post from Vox, click here.

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You Have Health Insurance, Now What?

Now that open enrollment is over, you have picked a plan, what is your next step?  Your next step is to use the plan you selected! Make sure you take full advantage of your health care coverage.  

Getting A Checkup…

Getting a checkup is something you must schedule on your calendar every year!  A checkup helps to create a baseline or a range of normal that is specific to you and your overall health.  Our healthcare system is designed to offer preventive care.  Preventive care is a proactive approach to healthcare where you and your doctor work together to identify potential issues before they become major problems.  

Below is a list of preventative care that is covered for adults.  When you visit your doctor, it is a good idea to ask them to address these screenings during your visit.

  1. Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
  2. Alcohol misuse screening and counseling
  3. Aspirin use to prevent cardiovascular disease for men and women of certain ages
  4. Blood pressure screening
  5. Cholesterol screening for adults of certain ages or at higher risk
  6. Colorectal cancer screening for adults over 50
  7. Depression screening
  8. Diabetes (Type 2) screening for adults with high blood pressure
  9. Diet counseling for adults at higher risk for chronic disease
  10. Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
  11. Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 – 1965
  12. HIV screening for everyone ages 15 to 65, and other ages at increased risk
  13. Immunization vaccines for adults — doses, recommended ages, and recommended populations vary:
  14. Lung cancer screening for adults 55 – 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
  15. Obesity screening and counseling
  16. Sexually transmitted infection (STI) prevention counseling for adults at higher risk
  17. Syphilis screening for adults at higher risk
  18. Tobacco Use screening for all adults and cessation interventions for tobacco users

Please note that these services are free only when delivered by a doctor or other provider in your plan’s network.

Planning regular checkups and working together with your doctor is the best way to take proactive action when it comes to your health.

Do you have questions about your health plan and what it covers?  Schedule a FREE consultation with me by calling:  (813) 391-3448

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What is a Catastrophic Plan and are you Eligible?

When selecting health insurance during open enrollment, you may decide to select a “Catastrophic Plan.”  To do so, you must meet certain criteria in order to be eligible for this type of plan.

Defining a Catastrophic Plan

Catastrophic health insurance plans have low monthly premiums and very high deductibles. They may be an affordable way to protect yourself from worst-case health scenarios, like getting seriously sick or injured.

Most routine medical expenses are paid by you if you elect this type of plan.

You are only eligible for this plan if:

You are under 30 OR you are of any age and you have a hardship exemption or affordability exemption. These exemptions are based on Marketplace or job-based insurance is unaffordable.

What’s Covered?

  • Catastrophic plans cover the same essential health benefits as other Marketplace plans.
  • Catastrophic plans cover certain preventive services at no cost.
  • Catastrophic plans cover at least 3 primary care visits per year before you’ve met your deductible.

How much do they cost?

  • Monthly premiums for this type of plan are usually low,
  • Deductibles:  Deductibles are the amount you have to pay on your own for most services before the plan starts to pay anything.  These can be very high for this type of plan.  For example, the deductible for this plan during 2017, for all Catastrophic plans is $7,150. After you spend that amount, your insurance company pays for all covered services, with no copayment or coinsurance.

This can be very confusing and it may be difficult to make the best choice for you and your family.  The good news is, I am here to help!  Let me help guide you through the open enrollment process this year so that you can make an informed decision.

Schedule your FREE consultation by calling:  (813) 391-3448

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Making Open Enrollment An Easy Process

Open enrollment for 2018 health insurance coverage is right around the corner.  The enrollment dates are November 1, 2017, through to December 15, 2017.  All health insurance coverage, decisions, and selections you make during the open enrollment period will be valid beginning January 1, 2018.

Before open enrollment begins on November 1, 2017, there are some things you will want to gather before you speak with a qualified agent.  Your agent will need to know who will be covered under your plan and the type of insurance required.  

Below is a comprehensive list of the items you will need in order to make a sound and educated decision on your health care coverage.  

If you already are covered then it’s very easy. You just need to advise your agent if any of the items below have changed over the past year.

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 2018
  • A list of any major life changes for each member of your household getting coverage such as  Marriage, Income, Moving, Births, Divorce, etc.

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. 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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Why It Is More Important Than Ever To Have A Knowledgeable and Reputable Health Insurance Agent

In an article I recently read, entitled “ObamaCare Advocates:  Hole Too Deep to Make Up Outreach Cuts” it states that the Trump Administration has cut 90% of the funding set aside for educating the population on their options for health care coverage.  What does this mean for you?  In short, you may be losing out on critical information you need to make an informed decision about health care coverage for you and your family.

It is speculated that this cut could result in fewer people getting the health care coverage needed due to not knowing or being aware of the open enrollment periods and deadlines, what types of coverage is available, how health care coverage works and how to navigate the system.  A recipe for disaster for the average American.

With this new cut, it is more important than ever to have a knowledgeable and reputable health insurance agent represent you to ensure you are getting the health care coverage you need and deserve, on time!  Not all agents are created equal!  When selecting an agent, select someone who is:

  • Professional and who is responsive and available to take your phone
  • Well educated when it comes to the Affordable Care Act
  • Informed and stays on top of Affordable Care Act current events
  • Understands the law
  • Will listen to your needs and will consult with you about your best options

If you are concerned about the upcoming open enrollment period, how much health care coverage you need for you and your family and how to avoid potential fines, I can help!  Visit my website for FREE valuable tools like “Dave’s Doctor Search” and a list of resource links.  Follow me on Facebook to learn about your healthcare options, breaking news and to get connected!

Do you have questions or need help navigating the health insurance system?  I am happy to help! Schedule your FREE consultation: (813) 391-3448

Doing my part in Making Healthcare Great Again!