Do You Have "CoPayItis"?

Chances are pretty good if you have every purchased your own health insurance policy... but don't worry, it's quite curable!

Well.. just what is this anyway, you ask, particularly if the chances I have it.. and how did I get it?

The answer is quite simple.. When you went to evaluate the purchase of a health insurance policy, you were probably offered a co-pay fixed amount for a doctor visit and quite possibly a prescription plan.

Now you thought, "this is good".. "I'll know exactly what I have to pay to go to the doctor". Hmmm ---but do you know 1) If that covers only the visit and diagnosis part, or does it also cover any injections, in office xrays, and blood work, and 2) Do you know what these might cost with OUT the copay feature?

Most people don't, and it's that unknown, and fear of that unknown that lead many.. make that MOST... people to take the copay option. Gives you some peace of mind, but does it give your wallet the best deal?

The answer is almost always a rousing "NO". But it gives the insurance companies a great warm fuzzy feeling! It's a real cash cow for them, with them banking on you not knowing "the other side of the story".

Here's that "other side":

First, doctors office visits and this copay generally only cover the visit, the records, probably the writing of a prescription.. but not necessarily the other diagnostics which may include blood work, etc. Be sure and see what this coverage is as you review your policy.

For discussion sake of this article, let's assume ONLY the doctor office part is covered.

Now most doctors have at least a two tier pricing schedule. The top tier is for those with no insurance and no insurance affiliation. Call this the "list price" or the "sticker price". It's almost always what you will pay unless you have insurance or ASK for a discount. Secret Tip: You can almost always get the discount if you ask. What grounds? Try, "I'm part of the human race, a large contingious group".

The second tier is for those who generally belong to, or participate in, one of the provider networks the doctor belongs to. In fact, he or his practice, unless controlled by an HMO, probably belongs to many of the various networks. Prior to selecting a doctor, you always need to find this out. People who are members of this get the PPO or network discount. It will vary among the doctors and networks, so again, as you plan your medical care, it's up to you to find out what it is.

OK.. back to your little case of "copayitis".

If your doctor "list price" for a call is $100, but you would only be billed $60, you need to know this.

Now in your insurance plan you opt for, or take a "doctor visit copay of $35". Pretty typical. As typical is that the plan may state "for up to four visits a year". In other words, if you take this plan, you save $25 per visit. Let's say you normally go to the doctor 4 times a year. You saved $100.

Now here is where it gets interesting!

When you look at your policy, you see the "bottom line"... generally $x per month. But did you notice that this figure is made up of many components such as the deductible, the copay, the max copay limit cap, the Rx plan and POSSIBLY THE DR VISIT COPAY? Bet you didn't, and chances are pretty good your agent might not have pointed it out. Why? Because he knows emotionally most of his clients want it. It gives them a feeling of good security, and it's one of the top five questions agents get, "What's the copay for my doctor?"

Heck, I'm an agent. Why rock the boat? Half my clients only want a quick bottom line number; don't bore me with the details! I have more important things to do like figuring out if my new HDTV will be a plasma screen or not, or how many pixels the resolution is!

But as you ARE reading this, let's assume you are interested and concerned. Good for you.

OK..In a typical policy, lets say for just you now (and there really is not "typical".. but his is a practical example) the CoPay option adds $17.00 per month to the plan. The copay is $35, saving you $25.. but your policy only pays up to 4 visits on this copay. Your max savings is $100. But you are paying $17/mo x 12 mos a year, or $204. Now does it make sense? Of course not. Assuming you did go to the doctor the times, your cost was $104. If you didn't go at all, you paid $204 for a feature you never used.

The same type of example and situation can apply to prescriptions where the copay premiums will vary from each policy depending on what prescriptions you are taking at time of application, and what will be covered. Some may not be covered at all due to pre existing rules, others result in a policy rateup.

And if you stick with this company, as this option is a part of the major medical plan, it will increase each year.. 15-20%!

So how do you cure your "copayitis"? By asking your agent to show you the other and less traditional ways to minimize your exposure to the doctors office calls.

You see, as I have told many of you who I have spoken with, the purchse of Health Insurance is not all that straight forward but has some nuances.

The more you understand, the more you can save.

Most agents who work plain commission don't want to help you save! First, they are banking ont he odds that for most things, you'll never use the policy.. so you don't know or will never find out what you don't have.. BUT... two things like doctor visits and prescriptions occur every day, unlike the probabilities on major expenses for surgery or one of "the big five".

Become informed. Work with an agent who will take the time to help and explain to you, and will do so without you having to pry questions out of him or her!

Joe Leech

Licensed Agent.

"One of the Good Guys"