DOWNTOWN HEALTH & WELLNESS
  • Urgent Care
    • Urgent Care MEMBERSHIP PLAN
    • 24/7 Urgent Care
    • GMP
    • DOCTOR IS IN STL (Blog)
    • Our Locations >
      • Downtown Urgent Care
      • Creve Coeur Urgent Care
      • North City Urgent Care >
        • STL Accident & Personal Injury
    • Best Urgent Cares
  • Primary Care
    • Primary Care MEMBERSHIP PLAN (DirectYourCare.com)
  • Telemedicine
  • Work Injury
    • Employers >
      • Occupational Health >
        • Injury & Illness >
          • Employee Flu Shots & Vaccinations
          • Primary Injury Care
          • Medical Specialist
        • Pre-placement Services >
          • Drug Testing
          • Physical Examinations
        • Sending An Employee >
          • Our Services
        • Employer FAQs
        • Travel Health
        • CMCA Substance Abuse Management
      • On-site Employee Health Centers >
        • Types of Health Centers >
          • Primary Care Center
          • Occupational Health Center
          • Health & Wellness Center
        • On-site Technology
        • Savings and ROI
        • Employee Engagement
      • Health & Wellness >
        • Wellness Programs >
          • Health Assessments
          • Health Coaching
          • Wellness Education
          • Healthy Workplace Culture
          • Wellness Interventions
        • Health Screenings
        • Wellness Resources
      • Physical Therapy >
        • Our Philosophy
        • Ergonomics & Pre-Employment Testing
        • Physical Therapy Programs
      • The DMC Solution >
        • Employer Savings
        • Quality Medical Care
        • Patient Engagement
      • Consulting >
        • Medical Directorship
        • Medical Consultants
      • Our Clients

St. Louis Doctor Explains Insurance Lingo

6/3/2014

0 Comments

 
Picture
As more people are getting a private health insurance plan this year, many for the first time ever, there’s still a lot of confusion about what it all means. Dr. Saggar, the ‘Doctor is In’, is here to help understand a few of the words and phrases you hear being thrown around...

What do you mean by premium?Your premium or rate is what you pay each month for your health coverage. Your rate is based on the plan you select, where you live, your age and tobacco use for yourself and any dependents you may be covering.


What is a copay?

The copay is your share for the upfront cost, as the patient, for getting seen when you go and see a healthcare provider like a doctor or nurse practitioner. It’s usually a flat amount, such as $15 for a primary care visit, $50 to $75 for an urgent care visit, and $200 to $300 for an ER visit.


What’s a deductible?

The deductible is the amount you and your family has to pay before your insurance company actually starts paying for anything. For example, if your deductible is $3,000, that’s what you must pay before the plan will start to pay.

So plans with lower deductibles will have a higher monthly premium, and plans with a higher deductible will have lower monthly premiums.


What is coinsurance?

This word means the share of the health care costs you’re responsible for paying. It’s listed as a percentage. For example, if you choose a plan with 20 percent coinsurance you will pay 20 percent of the cost of care AFTER you’ve reached your deductible.


So what is meant by the ‘out-of-pocket maximum’?

The amount you have to pay each year for health care before it’s covered 100 percent by your plan. This is the most you’ll pay for care during the year. This includes three things: your copays, your deductible and the coinsurance, but not your premiums. In other words, only after you’ve paid (1) your monthly premium and (2) your copay and (3) your deductible and finally (4) your share of the coinsurance - only THEN will your insurance company start paying for your medical care.


Understanding this makes people wonder why they even have insurance to begin with! The answer: it’s important for those catastrophic things that you can never really afford to cut a check for, such as a big heart attack or stroke, getting hit by a truck or getting cancer.


What is a formulary?

A formulary is a list of medicines covered by your health plan. You’ll often pay a lower copay or coinsurance for formulary medicines than non-formulary medicines. This is usually because the insurance company has negotiated lower prices for one drug compared with another, so obviously they want you to choose the drugs that they have to pay less for.


What is my coverage outside of the network?

Most individual plans, but not all, have some kind of out-of-network coverage. This is important if you travel around the country, or if you want more choice. If your insurer has no out-of-network coverage, then you’re as good as uninsured if you go somewhere they don’t want you to go. Plans with no out-of-network coverage are usually the cheapest you can find.


The amount you pay (deductibles and coinsurance) for using out of network providers will be higher than if you receive care in-network. Again, the insurance companies have negotiated lower rates with the network providers, and hence try to steer you towards seeing their ‘favorites’, because it’ll cost them less money.


What is the Direct Care network?

Direct Medical Care, aka DMC, is a capitated model, which a growing number of people are using throughout the country, in an effort to reduce or eliminate their out-of-pocket costs. For a low fixed monthly fee, like $59/month in Saint Louis for example, you can get primary care or urgent care, and never pay a penny for a copay, deductible or coinsurance again, for that particular kind of visit. The good thing is that over 80% of visits are primary care or urgent care, so this really does help cut your costs dramatically.


So, if you get a [much cheaper] catastrophic or bronze insurance plan with a direct medical care plan, then your out-of-pocket expenses are limited to around $700 per year if you can restrict your visits to primary care or urgent care, and things are a lot more predictable.


So why should we get health insurance?

Chiefly because of the serious catastrophic big stuff that could happen.

Our out-pocket-costs far exceed the value we get for them when we use insurance for the ‘small-ticket’ items such as urgent care or most ER visits, but we continue to want to have health insurance as a nation, because we’ve been hypnotized to believe that we are somehow exposed or suffering without it. Prevention of disease for those who are perfectly healthy, in the form of an annual physical with your physician or nurse practitioner, is definitely a good idea, but this can still be done affordably without all the copays, deductibles and so on, associated with health insurance.


In summary, insurance was originally created for big-ticket catastrophic problems, much like car insurance, so we should use it for that. For the small stuff, use a much cheaper option in the form of a Bronze plan plus a monthly plan such as DirectMedicalCareUSA.com




0 Comments



Leave a Reply.

    AS SEEN ON TV

    RSS Feed

    Blog
    DOCTOR IS IN STL
    Also featured on KPLR every Monday lunchtime, and all over the media in St. Louis. Click the bottom of the big screen below. 

    Author
    Dr. Sonny Saggar

    I am an emergency physician, general internist and urgent care physician. I'm also the Medical Director of St. Louis Urgent Cares

    Archives

    November 2018
    July 2018
    June 2018
    October 2017
    September 2017
    February 2017
    December 2016
    October 2016
    August 2016
    March 2016
    November 2015
    December 2014
    November 2014
    September 2014
    August 2014
    June 2014
    February 2014
    January 2014
    December 2013
    November 2013
    October 2013
    September 2013
    August 2013
    July 2013
    June 2013
    May 2013

    Categories

    All
    Acetaminophen
    Affordable Care Act
    Affordable Health Plans
    Alternatives To ER
    Alternative To Er
    Annual Physical
    Antibiotics
    Aspirin
    Avoid The ER
    Bronchiolitis
    Bronchitis
    Bronze Plan
    Calcium
    Catastrophic Plan
    Cayenne Pepper
    Cheap Medical Care
    Children's Ear Infection Treatment St. Louis
    Cholesterol
    Choosing Between Er Or Urgent Care
    Choosing Health Insurance
    Christine Buck
    Circulation Cold Shower
    Coinsurance
    Cold Shower Benefits
    Common Sense Choices For Acute Care
    Common Sense Healthcare
    Concussion St Louis
    Copay
    Cough
    Coughing Up Mucus
    Creve Coeur Urgent Care
    Dairy
    Deductible
    Depression Cold Shower
    Direct Medical Care
    Directmedicalcareusa
    Directmedicalcareusa.com
    Direct Primary Care
    Direct Primary Care St Louis
    Direct Urgent Care
    Direct Work Compo
    Downtown Urgent Care
    Dpc
    Dr. Sonny Saggar
    Ear Ache
    Ear Ache St. Louis
    Ear Infection
    Ear Infection St. Louis Urgent Care Open Late Urgent Care
    Ear Wax
    Emergency Medical
    Environmentally Friendly Cold Shower
    Erectile Dysfunction Cold Shower
    Er Versus Urgent Care
    Essential Coverage
    Essential Health Services
    Eureka Urgent Care
    Fever
    Flu Shot Makes You Sick
    Flu Shot St Louis
    Free Clinics
    Free Flu Shot
    Grace Hill
    Grace Hill Free Clinic
    Green Sputum Yellow Sputum
    Handkerchief
    Health Insurance
    Herd Immunity St Louis
    High Deductible Disorder
    Homemade Lemonade
    Honey
    Humidifier
    Ibuprofen
    Immunity Cold Shower
    Indigent Care St Louis
    Insomnia Cold Shower
    James Bond Shower
    James Sandler
    Lemon
    Lettuce Leaf
    Limits On Coverage
    Lozenges
    Lymphatics Cold Shower
    Metabolism Cold Shower
    Missouri Medicaid
    Myrtle Hillard
    Myrtle Hilliard Davis Free Clinic
    North City Urgent Care
    Old Wives' Tales
    Open Saturday
    Otitis Externa
    Otitis Media
    Patient Advocate
    Peoples Clinic
    Peroxide
    Pets Autism
    Pets Baby Immune System
    Pets Baby Immunity
    Pets Better Mood
    Pets Healthy Heart
    Pets Social Magnet
    Pets Stress Soother
    Plant-based
    Pranayama Cold Shower
    Preexisting Conditions
    Prevention Better Than Cure
    Preventive Care
    Primary Care
    Q-tip
    Respiratory Syncytial Virus
    Rhc
    Rsv
    Runny Nose
    Salt Water Gargling
    Scottish Shower
    Screening
    Sesame
    Skin Cold Shower
    Sonny Saggar
    Sonny Saggar Cold Shower
    Sore Throat
    Sperm Count Cold Shower
    Sports Injury St Louis
    Stl Sports Clinic
    Sunshine
    Swimmer's Ear St. Louis
    Tea Bags
    Tehina
    The Doctor Is In Stl
    Tick
    Tick Bites
    Tick Bites St. Louis
    Turmeric
    Turtle Neck
    Uninsured Care St Louis
    Unnecessary CT Scans
    Urgent Care
    Urgent Care Monday Evening
    Urgent Care Primary Care
    Urgent Care St Louis
    Urgent Care St. Louis
    Urgent Care Sunday
    Urgent Care Weekends
    Vegetarian
    Viral Bronchitis
    Vitamin D
    Walk-in Medical Center St. Louis
    Warm Grape Juice
    Weight Loss Cold Shower
    Why Not Q-tips
    Winter Sun
    Yearly Medical

    RSS Feed

    Picture
    Picture
    Picture

If you believe you have a true medical emergency,  please call 911 now.


NOT the biggest, but we really are the best. 
STLHealthWorks is Much More Than Just Urgent Care.
We include Urgent Care, Primary Care, Telemedicine, and Occupational Medicine.
Putting People Before Profit.
Picture
Email us:
health@dhwstl.com
Call us: 1-844-YOU-URGENT 
(1-844-968-8743)
Every attempt is made to answer emails and respond to voicemails by the end of the business day.

Downtown Urgent Care
​916 Olive Street, Saint Louis, MO 63101
​314.436.9300

OPEN 24/7
​EVERY SINGLE DAY OF THE YEAR
Fax 314.925.1305
Creve Coeur Urgent Care
13035 Olive Boulevard, Creve Coeur, MO 63141
​314.548.6550
​
Monday to Saturday: 10am-6pm

​Sunday: CLOSED
Fax 314.925.1305
North City Urgent Care
6113 Ridge Avenue, Saint Louis, MO 63133
314.932.1213
Monday to Friday: 10am-6pm

​Saturday and Sunday: CLOSED
Fax 314.925.1305

Downtown Health & Wellness © 2008 to 2018
Picture
Downtown Health & Wellness Mindfulness

Not just Urgent Care and Primary Care!

We strongly believe that PREVENTION REALLY IS BETTER THAN CURE. 

Downtown Health & Wellness is the home of carefully appointed Mindfulness & Meditation Spaces, where you can come and visit as a group, have a retreat as a group, just talk among yourselves in a beautifully themed space, or partake in some of our services, such as guided meditation, group yoga, group acupuncture, massage, cycling, hiking, horseback riding, kayaking and even get an executive physical. 

Learn more at STLMindful.com

  • Urgent Care
    • Urgent Care MEMBERSHIP PLAN
    • 24/7 Urgent Care
    • GMP
    • DOCTOR IS IN STL (Blog)
    • Our Locations >
      • Downtown Urgent Care
      • Creve Coeur Urgent Care
      • North City Urgent Care >
        • STL Accident & Personal Injury
    • Best Urgent Cares
  • Primary Care
    • Primary Care MEMBERSHIP PLAN (DirectYourCare.com)
  • Telemedicine
  • Work Injury
    • Employers >
      • Occupational Health >
        • Injury & Illness >
          • Employee Flu Shots & Vaccinations
          • Primary Injury Care
          • Medical Specialist
        • Pre-placement Services >
          • Drug Testing
          • Physical Examinations
        • Sending An Employee >
          • Our Services
        • Employer FAQs
        • Travel Health
        • CMCA Substance Abuse Management
      • On-site Employee Health Centers >
        • Types of Health Centers >
          • Primary Care Center
          • Occupational Health Center
          • Health & Wellness Center
        • On-site Technology
        • Savings and ROI
        • Employee Engagement
      • Health & Wellness >
        • Wellness Programs >
          • Health Assessments
          • Health Coaching
          • Wellness Education
          • Healthy Workplace Culture
          • Wellness Interventions
        • Health Screenings
        • Wellness Resources
      • Physical Therapy >
        • Our Philosophy
        • Ergonomics & Pre-Employment Testing
        • Physical Therapy Programs
      • The DMC Solution >
        • Employer Savings
        • Quality Medical Care
        • Patient Engagement
      • Consulting >
        • Medical Directorship
        • Medical Consultants
      • Our Clients