I have health insurance!!! Let's go get everything done starting from blood work, MRIs, and regular professional massages, on top of my P.T. and prescriptions. Woohoo!! ...Right? TLDR, this blog is written at a time where I get palpitations and Bell's Palsy symptoms just thinking about insurance companies. This is in my case the most Blooggggiest blog I can perform at the moment (and also an attempt to deal with the stress of dealing with insurance companies).
Do insurance companies really want to help us? How do we know who to trust? This blog isn't going to answer either of these questions directly, but it will hopefully give you an idea of what to look for when trying to understand your OWN health insurance plan.
You may have gotten a new insurance plan or have had a plan through your work and they just changed up who their preferred insurance company is. Now what does that mean for you?
It means that you have to go through your NEW plan and check out all the details and compare/contrast with the OLD plan to see if you can continue with what you were doing last year. Easy right? Well... it depends. (<< that seems to be the best answer for everything these days -____-) It depends really on how user friendly the membership interface portal is and how well they lay out your member benefits. If you are computer-savvy, then you can quickly discern whether or not there is clarity in your member benefits package. If you are not computer-savvy, then you might find yourself in a trap trying to understand things that your insurance company may not want you to understand... I'm on the provider side of this, and let's just say its not too pretty.
After sifting through the details of my own insurance plan, I have realized that I can go to the urgent care or the emergency room and pay ZERO for my services rendered. However, if I elect to go to the doctor's office for a checkup, I will be paying full price until my deductible is met. It turns out, these services are excluded from the deductible and I am not responsible for payment. However, if I plan a service out and go to the appointment, I'll get dinged with a payment. Does it seem right? Welp... It's what I paid for and it is what I got.
Not that I have written insurance policies (or even understand them really), I have gained a little experience and have gathered a few buzz words for you to take into consideration when reviewing your member benefits package.
Buzz Words and Phrases
Member Benefits - Service Types
This is the meat and potatoes of your health plan. Make sure you understand the basics of this before you go to a healthcare provider and say "I have insurance, here is my card". You may get hit with a bill that was MEANT for an insurance company, but now you are paying the price - literally.
Some examples of service types are Hospitals, Emergency Services, Urgent Care, Chiropractic, Mental Health, Vision, Dental, Pharmacy - you get the idea. Some plans with straight up exclude some service types so be PLEASE aware of that. For example, with my "We got you if you get hit by a bus" insurance plan, there is ZERO vision or dental coverage.
Deductible
According to the googles, the deductible is the amount the MEMBER is responsible for before the insurance company with kick in their cut. I've seen deductibles as low as $0 to as high as $10,000 per individual. "Hey thanks for signing up for this health plan, just make sure to pay for the first $10,000 of everything health related, then we'll start paying after that." Meanwhile, you are de-incentivized to get healthcare, and the insurance company is kicking their feet up collecting their monthly premiums.
Co-Pay vs. Co-Insurance
These are the amounts you would pay for a service AFTER your deductible is met. Co-pays and co-insurances can be different depending on the type of service you are getting and are typically paid before the time of the service. Depending on whether the service provider you are going to is In-Network or Out-of-Network can also determine the amount of you pay for the service.
A primary care physician copay could be $25, but the copay for a specialist could be the same or higher (I've never seen a specialist copay be lower than the PCP).
Co-insurance is a percentage of the total amount billed by the healthcare practitioner, so it is a good idea make sure you know how much the service is before going into the appointment. Co-insurances can be as high as ... 100% PLEASE READ YOUR MEMBER BENEFITS!!!!!
In-Network or Out-of-Network
Hospitals, doctors offices, dentist offices, or any healthcare office can elect to be in-network (IN) or out-of-network (OON) with your insurance plan. As a member, this can determine the amount your co-pay or your co-insurance per service.
Typically, providers that are in-network will give you less financial responsibility (as in cheaper co-pay and co-insurance), but that means you have to see their preferred practitioners. If you like a doctor's office but they are out of network, it means that you will have a higher financial responsibility to go to your doc of choice.
Out of Pocket Maximum
An out-of-pocket maximum is exactly what it sounds like - the maximum you will pay out of pocket for that benefit period. Some benefit periods are Jan 1st - Dec 31st, others are July 1st - June 30th.
Whew. This concludes my first ever written blog. Are you cured of all your ailments? Yea... me neither. But hey - I do feel a little bit better! Hopefully you do too.
Thanks so much for taking the time out of your day to read my blaaaaaaaaahgggg.
Yours until further notice,
~Lenny