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Know Your Coverage

by Purchased & Referred Care | Jul 18, 2017
Does your current insurance cover Vision? Dental? Prescriptions? Medical?

If you are not sure, you should consult the Summary of Benefits and Coverage (SBC). Your insurance plan is required (by the Affordable Care Act) to provide a standardized comparison of the plans benefits, terms and conditions. If you do not have an SBC, call your plan and request it. This is usually a one to two-page summary that would clarify things like:
  • Are there services NOT covered by the plan?
  • Do I need a referral to see a specialist?
  • Do I need prior authorization from the plan for physical therapy? Surgery? Office procedures?
Vision: Does my plan cover exam only, or exam and some hardware? Am I required to use a network provider to obtain any of this coverage. Some plans ONLY cover network providers and cover nothing at other providers; zero benefits out-of-network. Do you know?

Is there coverage through the same plan as your medical (Regence, Aetna, Cigna etc)? Do I also have a special vision plan like VSP or Davis Vision? Samish needs to know what benefits you have from each plan so that we can process your claims correctly. If your medical plan covers part of the eye exam, we cannot pay our portion until we receive the Explanation of Benefits (EOB) showing your  insurance paid first. If your coverage has changed, and it no longer covers the exam, we will not be paying, waiting for something that will never arrive. This makes for unhappy patients, doctors and PRC staff.

Dental: Do you have dental coverage? Are there network restrictions? Is there an annual limit? Does the plan include orthodontia? Dentures? Fillings and exams are often covered at 80% to 100%. Crowns can be covered at 50%. A crown usually costs about $ 1200.00; a root canal about $ 1000. Many tribal dental facilities can perform these services at little to no cost to you or to Samish. For example, a crown at a tribal facility can cost $200 to $400, a major savings from the going rate. The tribal facility will bill your insurance, and for most services, accept that payment as payment in full. The staff in Purchased/ Referred Care can assist you in locating a tribal dental facility or a Medicaid/Apple accepting dentist.

Prescriptions: If your coverage includes prescription coverage, are you restricted to certain pharmacies? Some Group Health/Kaiser Permanente plans require that you use their pharmacies only. Please let us know if this is your situation so that we can exempt you from using Bellegrove.

For long term meds, those lasting longer than a month, we require that you use our mail order pharmacy, Bellegrove. Through Bellegrove we can access a deep government discount on many meds. The discount is not available to us from any retail pharmacies.

Short term meds (like antibiotics) can be purchased retail, but you may have to pay the full amount or co-pay and submit for reimbursement from NWPS. There is a list of meds that Samish can cover. The list is available to you on the Samish website. Samish cannot cover, in full or co-pay, if the medication is not on the approved list.

Medical: What are the in-network versus out of network differences? They can be significant. For example: on my plan, if I go out-of-network, I have a higher deductible to pay first. Then the usual 15 % co-pay jumps to 40% copay PLUS any amount over the allowed amount that the provider chooses to charge. With the higher deductible, that means I am paying in full for the office visit, instead of an in-network $ 30 co-pay. An average office visit is $200 +. Some out- of-network providers cannot bill your insurance, which means you must do the billing. You will contact your insurance to get the required forms, get the info (codes etc) from the doctors office and submit the bill to your insurance. You then get the check, pay the provider, give the provider any necessary paperwork and then they can bill us. This is a long, complicated process, and some providers are not willing to bill a secondary after that. Some providers routinely do not bill a secondary coverage (like Samish). If Samish does not get billed, we cannot pay. You are on the hook for the bill. Use in-network providers whenever possible.

Not knowing the details of your plan can cause all kinds of havoc. We have had patients physical therapy visits denied because the client or provider did not obtain required authorizations form the insurance plan. Samish cannot pay for services denied because the provider or client did not know what they were supposed to do. We have had clients’ services denied because the service was not covered by any insurance…the service has not yet been accepted as of value to the medical/dental
community. Samish cannot cover experimental/investigational services, even if your doctor orders them and wants them done. There are laboratory tests not covered without a supporting diagnosis (justifying the test). Always check with your insurance if in doubt. 

Has your insurance changed, and have you notified Samish PRC of the changes? If we do not have the correct info, your bills will not be processed properly. For all the folks with Group Health- now Kaiser Permanente- have you sent us copies of the new cards you received? What family members are included in your plans? Did your employer change your vision or dental coverage?

If Samish PRC has complete, accurate, current information about your coverage, we can serve you better. Incorrect information can lead to bills being denied unnecessarily, or paid incorrectly.