Insurance Coverage Information
By Steven Meier
Navigating the health insurance landscape can be confusing and somewhat overwhelming. Understanding the differences and limitations between different levels of coverage, and estimating what your out-of-pocket expenses and deductible amounts will be ahead of your appointment can save a great deal of time and stress.
Most private plans require that the patient meet a predetermined deductible amount before services are covered by the plan, as well as a co-pay and a percentage of the cost of services. Insurance plans work with a network of preferred service providers, and some plans offer limited coverage for services outside of the network at a lower benefit rate, but some plans do not offer out-of-network coverage. Please contact Meier Orthopedic Sports and Regenerative Medicine at 310-504-2988 with any questions about our billing policies and acceptable forms of insurance. If you are unsure whether your plan provides out of network coverage, please call to confirm prior to your appointment.
Different Types of Insurance Plan Categories
We accept all PPO plans from the major insurance carriers exclusive of Covered California plans (we do not accept insurance from plans purchased through the Covered California insurance marketplace exchange at this time). We also accept Medicare. Meier Orthopedic Sports and Regenerative Medicine does not accept HMO plans or insurance through MediCal at this time.
Major Health Insurance Carriers
- Blue Cross*/Blue Shield/Anthem
- Kaiser Permanente
- United Healthcare
- Health Net
Medicare plans are administered by the state of California and have specific fee schedules and coverage allocations. Medicare eligibility is generally for adults over the age of 65.
(*Individual plans may not provide out of network coverage.)
Health insurance plans are categorized according to the types of services included in the plan, and requirements for coverage:
PPO (Preferred Provider Organization)
A PPO plan allows patients to visit an in-network provider of their choosing without a referral from a primary physician. PPO plans cover in-network services at a higher rate. A portion of out-of-network services may also be covered by a PPO plan at a lower rate depending on the carrier, meaning the patient is responsible for paying a higher portion of the bill out of pocket than with a preferred in-network provider. PPO plans offer greater flexibility in choosing specialists without the need to get a referral from a primary doctor.
HMO (Health Maintenance Organization)
HMO plans offer services through a designated network of providers and require a referral from a primary physician in order to see a specialist. HMO plans generally offer lower out of pocket costs and little to no deductible for in-network services, with limits on allowable coverage amounts for out of network visits.
EPO (Exclusive Provider Organization)
EPO plans offer coverage for services within a designated network of providers and do not require a referral from a primary physician to see a specialist. EPO plans do not provide coverage for out-of-network services.
POS (Point of Service)
POS plans combine elements of PPO and HMO plans. Depending on the specific plan, conditions associated with HMO and PPO plans may apply, such as referrals for specialists from a primary care physician, lower co-pays and deductibles for in network services, and lower benefit rates for out of network providers.
Mirrored Health Insurance Plans
Private insurance providers that offer plans through the Covered California marketplace exchange also offer what is known as a “mirror plan” with the same benefits and coverage. Because benefit rates and coverage can vary considerably between plan types, it is very important to distinguish between a PPO and EPO plan to ensure that you are receiving adequate coverage through the plan of your choosing. Providers with mirror plans include Blue Shield EPO, Blue Shield PPO, Health Net, and Anthem. Contact your provider to ensure that your plan meets your coverage and desired benefit rate requirements. While coverage and benefits may overlap with many plans, EPO plans do not cover out of network services and will limit your ability to see a primary care physician and specialist of your choosing if they are not in network.
What Will I Owe at the Time of My Appointment at Meier Orthopedic Sports and Regenerative Medicine?
Co-pay and deductible amounts vary from plan to plan. Most PPO providers offer a bronze, silver, and gold option, with lower monthly premiums typically requiring a higher payment at time of visit and a lower benefit coverage rate, and higher monthly premiums offering lower co-pays and deductibles with a higher benefit coverage rate. Pricing for X-rays and other imaging services at our facilities varies depending on the body part. Review your coverage level and corresponding co-pays and deductibles for more information.
Contact us at 310-504-2988 for more information.
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