Patients often ask us, “Will my insurance cover this?”
It’s an important question, especially during these tough economic times.
Your insurance company is the only one who can tell you what your plan covers. There are many insurers out there and even the same insurance company can have different plans with different benefits. “Coverage” also means different things to people. A service or medication may be “covered” but you may still have to pay a large portion of the cost if you have a deductible.
In order to help our patients, we have compiled the following guidelines based on our experience. This is not a complete list and should serve as a guideline only. Any specific questions you have about coverage should be checked by calling your insurer.
If you change your health insurance, notify all your physicians to update your information.
Physical Exam vs Problem Visit
Many insurers do not cover physical exams. Most patients do not realize this. If you go to your physician for a ‘checkup’ but do not have any problems, your insurance may not cover the visit. Problem visits are generally covered.
Annual exam (Well Woman Check) vs Office Visit
A “Well Woman Exam” is what most women refer to as their Annual Exam. It is defined by most insurers as a “Cervical or vaginal cancer screening and a pelvic and clinical breast exam”. That’s it. If you are having any problems or concerns that you want to discuss with your doctor, the visit becomes an office visit. It is coded differently and your copayment may be different than what you pay for your Annual Exam.
Multiple Problems at the same visit
Most insurers do not cover multiple services if done on the same day. An Annual Exam and a Problem Visit may not both be covered. Or, for example, a patient comes in to discuss options for birth control and decides on getting the birth control shot. The shot may not be covered if she gets it the same day as the office visit. We realize that it is often inconvenient for people to come back for multiple visits, but the staff does their best to make sure that your visits will be covered.
Specific Health Plans
HMSA – HMO Plans: When you sign up for an HMO plan, you are required to pick an HMO “Group”. This “Group” is made up of physicians who have agreed to provide care to patients who have that HMO plan. Patients are expected to seek care from one of the doctors in the Group.Dr. Sato is participating with the following HMO Groups
· Pacific Health Care/PMAG
· Hawaii IPA
· Oahu Physicians Group
HMSA Quest: Quest patients all have a Primary Care Physician (PCP). A written referral from your PCP is required prior to any visits, except for routine Annual Exams. Without this referral, your visit will not be covered.
AlohaCare: Alohacare patients also have a PCP. A written referral from your PCP is required prior to all visits. If you do not obtain a referral, your visit will not be covered.
Medicare: Medicare covers a Well Woman Check once every 24 months for most women. (That’s right, an ‘Annual’ exam is only covered once every 2 years.) But they are one of the few insurers that will cover a checkup and problem visit on the same day.