Understanding your health plan and benefits

When you purchase health insurance, you are entering into a contract with the health insurance company. Your health plan sets the rules: what is covered, how much coverage you have for each service, which providers are in and  out of network, any special rules that restrict access to coverage and generally what your portion of the bill will be for each service. Review the information below to assist you with understanding common terms associated with your benefits and information you will need to obtain from your insurance provider.

Out-of-pocket-maximum

This is the most you will pay for your health care for the plan year. Once you have reached your out-of-pocket maximum for the plan year, your plan will pay 100% of any additional covered medical expenses for the rest of the plan year.

Co-payment (Copay)

This is a flat fee you pay for specific services (like office visits). Your copay is typically different for different types of services including primary care versus specialty care. We are a specialty care office. You pay your copay for each office visit until you reach your out-of-pocket maximum.

Coinsurance

For some health services, you share the cost of your health care with your health insurance plan. Coinsurance is the percentage of the total cost of your care that you will pay.

Deductible

This is the amount you pay for yourself each plan year before your health insurance plan will begin to pay for your care. Your deductible is part of your out-of-pocket costs.

Coordination of Benefits

If you have coverage from multiple health plans you will need to ensure that your benefits are coordinated with each plan. Contact each health plan to determine which plan is the primary payor, prior to scheduling an appointment.

General information you will need to obtain from your health plan before accessing healthcare services from Northwest Gastroenterology Clinic:

Is this healthcare provider in-network?

• If not, how can I find an in-network provider?
• If I choose to see this provider anyway (out-of-network), what will my cost be?

Does my plan provide coverage for this service?

• Are there limitations or exclusions to my coverage for this service?
• Does my plan require a Prior Authorization or Referral?
• Does my plan limit the number of visits that I am entitled to?

Will I need to pay a deductible?

• If so, how much is my deductible?
• When does my deductible reset each year?
• Do I have a different deductible for in-network and out-of-network providers?

Will I need to pay a co-payment or co-insurance?

• If so, how much?

Information to ask the health plan before having a procedure with Northwest Gastroenterology Clinic and NGC Endoscopy Services:

To help with determining what you can expect to pay for your colonoscopy:

Review the guidance about paying for your procedure here.

For all procedures:

• Is this procedure covered by my plan?
• Do I need Prior Authorization or Referral?
• Will the outcome of my procedure affect my cost-sharing?
• If I need a prescription filled (bowel preparation) for this procedure, is it covered by my pharmacy or medical benefit?
• If there are biopsies obtained, what is my responsibility of the cost sharing?