By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
November 21, 2024
A "year" is a year, right? Well, maybe not in healthcare.
Why not? Why should you care? Let's explore.
A. "Calendar" versus "Business"
A "Business" day is a day that is not a weekend or a legal holiday. Most weeks will therefore have only five days in healthcare, a "business" year will have, on average, 250 days.
A "Calendar" day is every consecutive day that includes weekends or legal holidays. A "calendar" week has seven days, and a calendar year is 365 days from the time the policy becomes active or renews.
B. The importance of the Start Date
When does the healthcare year start? It usually starts on the first day of the month you become eligible for coverage for a new insurance plan through a new employer, or when you purchase your own policy on the open market. But the plan may not renew, and a new "year" start, 365 days later!
If you are eligible for qualifying event, for example, you turn 26 and can get your own insurance, or have gotten married and now qualify to join your spouse's health plan, the start date can be any month.
As for renewal date, which resets a brand new "year", although it usually start again on January 1, some plans may start on the first of July or the first of October. It's health care, therefore anything goes.
C. Financial concerns
Because your out of pocket share of cost is calculated on a "yearly" basis, it is important to know when that year starts. That amount, which you must pay out of pocket before or during the time your insurance pays for medical claims, is set for a duration of 365 calendar days. However, if you come onto a new employer's plan in September, and the plan renews on January 1st, you will need to pay a deductible and co-insurance for the September to 12/31 period, then start from scratch on 1/1 until 1/31 of the following year. It is unfair, I know.
Should you switch insurance plan in the middle of a year, any met deductible or out of pocket is not transferable from one plan to another. Again, totally unfair.
Preventive services are free, but often only once during the "calendar" year during which the plan is active (jan 1 to 12/31 or 9/1 to 8/31). So if you policy renews or started on January the first, and you have a well physical exam on March 15 well don't have another one on October 31, that second one will not be free.
Limitations per year: for example 2 dental cleanings or 20 physical therapy sessions. This is again for the time period during which the plan is active (jan 1 to 12/31 or 9/1 to 8/31). Chiropractic, acupuncture, speech therapy, occupational therapy, home health services are often limited per year, as are days in a Skilled Nursing facility. Anything beyond that maximum will be applied toward your financial responsibility.
D. Tips
Keep track:
of your met share of cost/out of pocket. Once the max has been met, use the rest of the "year" to get services, follow ups, procedures, treatments, Rx refills, tests, scans as their allowance will be paid by the insurance @ 100% (at least In Network)
of the number of limited visits - such as ABA therapy for your autistic child or chiropractic sessions after your fall - that you use. Once you get close to the limit, ask your PCP or any treating/supervising physician for a letter of medical necessity, explaining why more visits/treatments/sessions are necessary to ensure recovery or improvement of your condition. The insurance's Authorization Dept can be contacted with medical records and treatment plans to review a special extension of benefits.
of what preventive services you have not yet taken advantage of, and that would be at no cost to you. Now, and before the "year" ends, is the time for those appointment
2. When in doubt, contact your insurance Eligibility representative, your HR department or insurance agent. Clarity on when a "year" starts is a necessity to take full advantage of your policy, and avoid unpleasant - and costly - bills later.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024™
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