Your insurance policy can be divided into medical (doctors, hospitals, etc.) and pharmacy plan/benefits. So you might have a deductible for medical and a separate deductible for pharmacy. Sometimes it’s the same (especially if it’s a high deductible plan). You will have separate deductibles and out of pocket maximums for in and out of network plans.

 

FSA and HSA: FSA and HSA are saving accounts that are specifically used for medical costs. Generally pre-tax dollars are put into the account if your employer is putting the money into the account when running payroll. Meaning, you don’t pay taxes on the money put into the account. If you use post-tax dollars but depositing directly into an HSA, you can usually request a credit for taxes in your tax return. FSA monies generally expire once a year (usually March 15) so you should only put in what you think you’re going to spend in a year. HSA is generally only available to those with high deductible plans, but the monies don’t expire in the same way as FSA.

 

GAP Exception or Network Deficiency: If you’re seeing an out-of-network doctor who does something special and you can’t get it in-network, you can request authorization from your insurance company for something called a GAP Exception or Network Deficiency. Basically you’re asking your insurance company to help cover something that isn’t provided in the network of doctors with whom they have contracted (hence the name, GAP or deficiency). Not all policies will allow this (especially self-funded policies), but always worth a shot! Every plan has a different process. Sometimes the doctor you want to see has to start the process, sometimes you have to start the process, sometimes an in-network doctor has to start the process (and state that they are referring you to this special doctor).

 

Prior Authorization: This is a request made by a doctor’s office for authorization, or permission, to perform a certain procedure or request a certain medication for you. These authorizations can take time to be done, and even longer for an insurance company to get back to you with an answer. When I perform prior authorizations for medications, I can get an answer back right away, or I might have to wait 72 hours for an answer. I have also waited up to two weeks for an answer about an authorization for an MRI!!  Now, that’s a bit unusual, but it can happen!

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Filed under: pain management

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