Understanding Your Insurance Options

For many of us this time of the year, you are starting to hear “it is open enrollment period”. But what does that mean and how does it impact you?

Open enrollment is a period of time when you are able to sign up for health insurance. Whether you have health insurance through your employer, enroll through the Affordable Care Act health insurance exchanges, or on Medicare, open enrollment will be the start for signing up for healthcare coverage.

It’s important to note that not all health insurance plans have the same open enrollment period, it depends on which healthcare plan you choose.

  • Affordable Care Act health insurance exchanges or the “Marketplace” – open enrollment runs from November 1, 2016 to January 31, 2017 to sign up for 2017 health insurance. For more information visit healthcare.gov.
  • Medicare – open enrollment began October 15, 2016 and is open until December 7, 2016. For more information visit medicare.gov
  • Health Insurance through an employer – this is set by your employer and can happen any time throughout the year. It is best to check with your human resources department regarding open enrollment periods. Many have open enrollment in the fall with new health coverage beginning in January of the following year.

There are also healthcare plans that do not have open enrollment periods, and if you qualify you can enroll at any time. Those plans are:

  • Medicaid – state-based health insurance program that lets you enroll at any time, if you qualify.
  • CHIP – Children’s Health Insurance Program led by the U.S. government that lets you enroll at any time, if you qualify.


Why is Health Insurance Important?

Getting hurt or sick is not something people want to happen, but unfortunately these unforeseen circumstances happen and having health insurance can help individuals and families cover high medical expenses.

It’s important to consider your health insurance options, as in 2014 it became the law for those who can afford health insurance to enroll otherwise you would have to pay a penalty. Healthcare.gov stated, “In 2016 the fine for failing to have health insurance is $695 per person in the household, $347.50 per child, or 2.5% of your total household income, whichever is greater.”

In addition to this rule, there are many benefits to having health insurance:

  • With the Affordable Care Act, or Obamacare, in effect, individuals who need health insurance no longer have to worry about healthcare plans paying a limit on medical expenses. For example, someone with ongoing procedures could reach millions of dollars in hospital bills. Once you reach your share of payment, maximum-out-of-pocket, health care plans will help cover the remaining cost with no maximum limit.
  • There is an equality rule under the Affordable Care Act where health insurance companies cannot discriminate/cancel individual health plans because of critical or chronic health conditions.
  • If you have a pre-existing condition, you will not be denied health care coverage. There are health insurance plans out there for everyone.
  • Under the Affordable Care Act, preventative services, such as certain screenings, vaccines, and checkups, are covered for free. This means you have access to preventative services at no cost, without having to meet your deductible.
  • For those that make an income between 100%-400% of the Federal Poverty Level, between $11,770 - $47,080 depending on the state according to healthcare.gov, there is cost assistance available to help lower your monthly health insurance expenses. This is called a tax credit or tax subsidy.

Questions about Health Insurance

Now you may be thinking, “Once I have health insurance how do I use it, or what do all these terms mean?” Both are great questions that many of us ask.

Navigating the health care system itself can be confusing and lead to these frustrating questions. According to the National Assessment of Adult Literacy, only 12% of adults in the United States are at a proficient level in health literacy obtaining, processing, and understanding basic information and services needed to make appropriate decisions regarding your health, so it’s no wonder why these questions arise.   

At Divine Savior Healthcare we are fortunate to have a variety of patient services that help answer your questions like this and take a pro-active approach to your healthcare needs.


Help with Your Coverage at Divine Savior Healthcare

On a daily basis, Linda Bannen, Concierge and Patient Advocate at Divine Savior Healthcare assists patients with questions about their health care plans and how it covers medical services received at Divine Savior. If you have questions, such as:

  • Does Divine Savior accept my insurance?
  • I am not sure what preventative services are covered with my insurance, and where do I go to get these services?
  • Why does my billing statement say I owe a co-pay? I thought my insurance covered at 100%?
  • What is an EOB?

These are all questions Linda can help with and can be reached at 608-745-6239.

If you have specific insurance questions related to higher priced medical needs, such as surgery, high- tech radiology, rehab services, referrals to other facilities, medications, and every day office procedures, Prior Authorization Specialists at Divine Savior Healthcare are available to help patients check their health coverage and understand options as they make these important healthcare decisions.

What is a prior authorization? Many health insurance companies require prior authorization to be completed before certain medical costs, such as the services listed above, are covered by your health care plan. Every day these specialists are working with insurance companies, finding the best coverage solution for you.  

If you’re a patient at any one of Divine Savior’s clinics or rehab services and need assistance with a confirming prior authorization for a medical service, ask to speak with one of our Prior Authorization Specialists. 


Health Insurance Terms to Remember

Premium: The monthly payment you make to the insurance company for your health care policy.

Out-of-Pocket Cost: The amount you must pay during a year for your health care in addition to your premium NOT included in your monthly premium. This includes any deductible, co-pay, co-insurance, or extra costs for services.

Deductible: The amount you need to pay before the insurance company will start to pay its part.

Copayment: One of the ways you share in your medical costs fixed amount. You pay a flat fee for certain medical expenses e.g., $10 for every visit to the doctor, while your insurance company pays the rest.

Co-insurance: The amount you pay to share the cost of covered services after your deductible has been paid. The co-insurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.

Explanation of Benefits: The health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the company paid and what portion of the costs you are responsible for.

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Experiencing a dull pain in the pit of your stomach

Stomach PainGastroesophageal reflux disease, or GERD, and gallbladder disease are two very common disorders. Knowing which one you have may be trickier than you think. Symptoms may be vague, such as a “dull pain in the pit of your stomach”, making it hard for you to explain to your doctor what’s exactly going on.

At Divine Savior Healthcare, General Surgeons, Dr. Eric Anderson and Dr. Joshua Pogorelec, have seen many patients with these symptoms and after further examination are able to help  diagnose and treat both diseases.

What is GERD?
Gastroesophageal reflux disease GERD refers to stomach contents moving into the esophagus causing a burning sensation commonly referred to as heartburn. Other symptoms may occur as well, such as pain in the upper abdomen, bloating, nausea and an acid taste in your mouth.  If this continue, prolonged exposure of the esophagus to stomach contents can result in damage to the lining of the esophagus.  This in turn can result in difficulty swallowing, pain with swallowing or permanent damage to the esophagus.

Although not all reflux results in symptoms or damage to the esophagus, common symptoms include:
• Heartburn
• Acid regurgitation
• Belching
• Difficulty or pain when swallowing
• Waterbrash sudden excess of saliva
• Dysphagia the sensation of food sticking in the esophagus
• Chronic sore throat
• Laryngitis
• Inflammation of the gums
• Erosion of the enamel of the teeth
• Chronic irritation in the throat
• Hoarseness in the morning
• A sour taste
• Bad breath
• Coughing at night

What is gallbladder disease?
The gallbladder is located below the liver on the upper right side of the abdomen. The main function of the gallbladder is to store bile, which is made in the liver and allows fat-soluble vitamins and nutrients to be easily absorbed into the bloodstream. Any condition that affects the gallbladder is considered a disease, and there are many different scenarios that fall under gallbladder disease:
• Inflammation
• Gallstones
• Common bile duct stones
• Biliary Dyskinesia
• Infection
• Perforated gallbladder
• Gallbladder polyps
• Porcelain gallbladders
• Gallbladder cancer

Dr. Anderson and Dr. Pogorelec share "the most common disease of the gallbladder is gallstones. Most people with gallstones do not even know they have them.  Once they cause problems, the gallbladder may need to be removed. Symptoms include pain below the right rib cage or in the “pit” of the stomach. This pain may radiate to the right upper back, chest, or shoulder. Other symptoms may include, bloating, nausea or vomiting, fever or chills, chronic diarrhea, jaundice yellow-tinted skin, or unusual lighter-colored stools or dark urine.”

After taking a closer look at GERD and gallbladder disease, Dr. Anderson and Dr. Pogorelec are able to provide helpful insight on common distinguishing factors between the two diseases.

Common distinguishing factors:
• Location: Although both may feel like a “pit in your stomach”, if you experience symptoms located closer to your throat or in your chest it is more likely to be GERD related. Symptoms located near your right lower rib radiating into your right upper back, chest and shoulder are more likely to be associated to your gallbladder.
• Pain: Unlike GERD, gallbladder pain usually begins suddenly, and changing positions, belching, passing gas or taking medications rarely helps pain symptoms go away.
• Timing: With heartburn being the most common symptom of GERD, symptoms of reflux are likely to occur shortly after eating, where symptoms of gallbladder disease usually occurs several hours after eating and have more consistent patterns of reoccurrence the same time each day.

What does treatment look like?
The symptoms of GERD are commonly and effectively treated with over-the-counter medications such as anti-acids and proton pump inhibitors. However, if relief does not go away from these medications your provider may recommend you be evaluated by one of our surgeons at Divine Savior.

After a thorough history and physical, our surgeons may recommend further evaluation of the esophagus and stomach with endoscopy.  Similar to colonoscopy, but without the need for prep, upper endoscopy allows the surgeon to visualize the esophagus, stomach and intestine to evaluate for damage to the esophagus, infection and a hiatal hernia.  Depending on the findings, further testing may be indicated to evaluate the function of the esophagus. 

Patients with severe GERD benefit from surgery to prevent reflux from occurring.  This procedure is commonly performed by both Dr. Anderson and Dr. Pogorelec, is minimally invasive, and very effective at treating GERD.  In fact, most patients no longer require any antacid medications after the procedure.

If you are found to have stones in the gallbladder causing symptoms, the best course of action is to have the gallbladder removed.  Leaving the stones in place will continue to cause pain and may result in serious infection of the gallbladder and bile ducts, jaundice or pancreatitis. 

Both Dr. Anderson and Dr. Pogorelec routinely perform minimally invasive removal of the gallbladder.  This is most often an outpatient procedure and very successful.  After a short recovery, most patients will find their symptoms are gone and they are able to live a normal life. 

If you experience symptoms related to GERD or gallbladder disease, or have concerns about either, it is best to consult your provider for further examination. Treatment for either disease varies person to person, but taking action immediately and being properly treated can help you prevent problems from worsening.

To schedule an appointment with Divine Savior Healthcare General Surgeons, Dr. Anderson or Dr. Pogorelec, call 608-745-5176.

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