Question: “What are copayments, deductibles and coinsurance – and how do they differ from one another?”
Answer: A “copayment” or “copay” is a specific dollar amount ($10, $15 or $20, for example) that you may have to pay for an office visit or a prescription drug. A “deductible” is a dollar amount (typically between $500-$3000) that you may be required to pay out-of-pocket each year before the health insurance company pays medical bills for some covered services. “Coinsurance” usually describes the percentage of a total bill that you may have to pay for certain services.
Things can get a little complicated when you want to understand how all these things work together, but here are a few things to remember. First, keep in mind that not every plan has a deductible or coinsurance – though many high quality plans do. Second, be aware that many preventive care medical services (check-ups, immunizations, etc.) may be covered at no out-of-pocket cost, even if your deductible has not been met for the year. Third, remember that copayments and coinsurance don’t usually count toward your annual deductible – though you may have an “annual out-of-pocket limit” that puts a ceiling on how much you can be expected to pay out-of-pocket each year for covered services. Lastly, some plans have more than one deductible. For example, a health insurance plan may have a standard deductible that applies to most medical services and a prescription drug deductible that only applies to prescription drugs.
Question: “Can my application for individual or family coverage be declined? Are pre-existing medical conditions covered?”
Answer: Until 2014, when the last major consumer provisions of the health care reform law come into effect, it was still possible for adults in most states to be declined coverage due to a pre-existing medical condition. There are a few exceptions. Several states (among them New York and Massachusetts) will not allow insurers to decline an applicant on this basis. And as a result of health care reform, children under age 19 can no longer be declined coverage solely on the basis of pre-existing medical conditions – though they may have to wait for special open enrollment periods to enroll.
Not all pre-existing medical conditions will result in a declination of coverage. If your application for individual or family coverage is approved, the insurance company may or may not require a waiting period before coverage of certain conditions begins.
Question: “How long do I need to keep this health insurance policy? What if I don’t need it for very long?”
Answer: Unlike employer-sponsored health insurance plans that might lock you into your coverage for a year, individual and family plans that you buy on your own can be cancelled at any time. You’ll typically pay for your coverage on a month-to-month basis. When you want to discontinue your coverage, contact your licensed agent or the insurance company directly.
Question: “Can I buy a health insurance policy from one state and use it in another?”
Answer: Health insurance is regulated on a state-by-state basis and each state has its own health insurance market. Buying health insurance across state lines is not allowed at present – and the fact is that it wouldn’t make much sense to do so. Health insurance companies negotiate with doctors and hospitals in their state or local area to secure discounted prices on medical services for their members. That’s one of the basic benefits of health insurance. However, health insurance companies do not typically negotiate discounted rates with health care providers outside of their state. As a result, if you were to buy a plan in one state and use it in another, you would probably have to pay more for your medical care than if you bought a health insurance policy for your own state.
Question: “What is an HSA? Can I pay my monthly premiums using HSA funds?”
Answer: HSA stands for “Health Savings Account.” HSAs are special savings and investment accounts designed to be used only in conjunction with qualifying high-deductible health insurance plans. Because qualifying health plans often have higher annual deductibles, they typically come with lower monthly premiums, which can make them attractive to many consumers. If you have an HSA-eligible health insurance plan, you may also open an HSA and make deposits to it on a tax-advantaged basis up to an annual limit, so long as those funds are used to pay for qualifying medical expenses. HSA funds cannot, however, be used to pay for monthly premiums.
Deposits to your HSA can be made either by yourself (in which case they’re tax-deductible) or by your employer (on a pre-tax basis). Funds can grow from year to year and be invested at your discretion to earn interest on a tax-free basis too. You can use those funds to pay for copayments, deductibles, prescription drugs and a whole host of other medical services (but not monthly premiums!). If you use funds in your account to pay for anything other than qualified medical expenses, you will face tax consequences at the end of the year.
YOUR PODIATRIC PHYSICIAN TALKS ABOUT MEDICARE
Podiatric medicine is a branch of the health sciences devoted to the medical and surgical care of the foot and ankle, and related or governing structures. A doctor of podiatric medicine (DPM) specializes in the prevention, diagnosis, and treatment of foot and ankle disorders resulting from injury or disease. A DPM makes independent medical judgments, prescribes medications, and when necessary performs surgery.
Podiatrists help our aging population to remain active and independent by keeping them ambulatory. Congress recognized this important relationship between foot health and general health when it included the services of podiatric physicians in the Medicare legislation.
Misconceptions of Medicare
Medicare coverage can often be confusing. The rules and regulations can easily be misunderstood by patients. One misconception is that Medicare covers only surgical procedures, but not medical care or routine foot care.
In truth, Medicare will cover routine foot care under certain conditions. According to the Medicare Rules and Regulations Manual, “Certain foot care procedures that are generally considered to be routine — e.g., cutting or removal of nails, calluses or corns — may pose a hazard when performed by a nonprofessional person on patients with a systemic condition that has resulted in severe circulatory problems or areas of desensitization in the legs or feet. Routine foot care performed under these circumstances is covered.”
The manual also states, “Services ordinarily considered routine are also covered if they are performed as a necessary and integral part of otherwise covered services such as the diagnosis and treatment of diabetic ulcers, wounds, and infections.”
Treatment of many diabetic foot conditions, both medically and surgically, is therefore covered by Medicare. Treatment of broken toes, burns, and arthritic conditions — gout, for example — are other covered conditions. (The misconception that Medicare covers only surgery may be caused by the fact that the Medicare code numbers assigned to diabetic treatment, such as that mentioned in the manual, and other nonsurgical procedures are listed under the “surgical” section of the code book.)
Coverage Under Medicare
If you have signed up for medical insurance (Part B) under Medicare, you are covered for certain services of podiatrists and other doctors for:
Medical and surgical services in the hospital, skilled nursing facility, office, or your home. The same action also provided that podiatrists can certify and re-certify medical necessity for hospitalization, skilled nursing care, and home health care.
Payment for routine foot care may be made for such care only when it would be hazardous to the health of the patient if self-treatment were performed. For example, when a beneficiary is under the care of a doctor for diabetes, circulatory ailments or certain other conditions, and evidences complicating local symptoms, routine foot care is a covered service.
Other prescribed health services, including diagnostic x-ray, surgical treatment, fracture casts, and leg or ankle braces that are attached to the outside of the shoe.
Drugs which cannot be self-administered and which are administered to you as a part of professional services.
Full reasonable charges for radiology and pathology services as a bed patient in a hospital, if you have both hospital and medical insurance.
Certain foot care services are not covered, no matter whether they are performed by podiatrists, medical doctors, or osteopaths. They are:
Routine foot care. This includes the cutting or removal of corns or calluses, trimming of nails, and routine hygenic care, except as noted above.
Treatment of flat-foot conditions, including arch supports.
Treatment of partial dislocations.
Reimbursement Under Medicare
Your medical insurance (Part B of Medicare) helps pay for the services of podiatrists and other doctors, out-patient hospital services, medical services and supplies, and other health care services.
Subscribers to medical insurance pay a monthly premium and the Federal government covers the remaining costs of the program. Medical insurance pays 80 percent of the Medicare-allowed amount, after the individual pays an annual deductible for covered services connected with the diagnosis or treatment of illness and injuries. Payment for services of a podiatrist or another doctor can be made as follows:
If you and your podiatrist agree, application for the medical insurance payment for covered services will be made by the podiatrist who will receive the payment directly from Medicare.
If you desire it, you may pay the doctor directly, and the medical insurance payment can be made directly to you.
In either case, you are responsible for the annual deductible and the 20 percent coinsurance amounts. Under either of these two payment options, the podiatrist is required to complete the necessary Medicare claim forms for you.
Note that, in some cases, you may also be charged amounts in excess of the Medicare-allowed fees and for services not covered under the Medicare program.
See “Your Medicare Handbook” for more information.
Prompt Care Of Foot Disorders
With advancing years, the skin and nails of the feet frequently become dry and brittle, and numbness and discoloration often are present. These may be the first signs of such serious conditions as diabetes, arthritis, and circulatory disease. Ignoring these symptoms and failing to seek prompt professional medical care when they appear can have serious consequences for patients, especially the elderly.
Foot Problems Can Be Prevented
Whether the older person lives at home or elsewhere, preventive foot care can:
- Increase comfort
- Improve or maintain mobility and independence
- Limit the possibility of additional medical problems
- Reduce the chances of hospitalization
- Lessen requirements for other institutional care
Consult Your Sugar Land & Houston Podiatrist
You may receive treatment from your podiatrist in the office, your home, the hospital, a nursing home, or an extended care facility. Always consult your podiatrist when you have questions about foot conditions or what is covered by Medicare.
Top Ten Foot Health Tips
Diseases, disorders, and disabilities of the foot or ankle affect the quality of life and mobility of millions of Americans. However, the general public and even many physicians are unaware of the important relationship between foot health and overall health and well-being. With this in mind, the American Podiatric Medical Association (APMA) would like to share a few tips to help keep feet healthy.
1. Don’t ignore foot pain—it’s not normal. If the pain persists, see a podiatric physician.
2. Inspect your feet regularly. Pay attention to changes in color and temperature of your feet. Look for thick or discolored nails (a sign of developing fungus) and check for cracks or cuts in the skin. Peeling or scaling on the soles of feet could indicate athlete’s foot. Any growth on the foot is not considered normal.
3. Wash your feet regularly, especially between the toes, and be sure to dry them completely.
4. Trim toenails straight across, but not too short. Be careful not to cut nails in corners or on the sides; it can lead to ingrown toenails. Persons with diabetes, poor circulation, or heart problems should not treat their own feet because they are more prone to infection.
5. Make sure that your shoes fit properly. Purchase new shoes later in the day when feet tend to be at their largest and replace worn-out shoes as soon as possible.
6. Select and wear the right shoe for the activity that you are engaged in (e.g., running shoes for running).
7. Alternate shoes—don’t wear the same pair of shoes every day.
8. Avoid walking barefooted—your feet will be more prone to injury and infection. At the beach or when wearing sandals, always use sunblock on your feet, just as on the rest of your body.
9. Be cautious when using home remedies for foot ailments; self-treatment can often turn a minor problem into a major one.
10. If you are a person with diabetes, it is vital that you see a podiatric physician at least once a year for a check-up.
Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manners of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.