Understanding Your Health Insurance Coverage: Get What You Paid For!

Karen Vogel

Demystifying Health Insurance

We all have encountered communications from health insurance companies that seem designed to confuse. How can you be a more informed consumer and make sure you are getting what you paid for?

 Learn the Terminology

Do you understand the difference between a deductible, a copayment and coinsurance? These amounts greatly affect how much you will spend in addition to the monthly premium, or as insurers like to say, your “out-of-pocket.”

Follow the Timelines

Every year, Medicare (coverage for people over age 65)has anopen enrollment period from October 15 – December 7. For plans bought through a State Exchange, enrollment starts November 1 and ends December 15 for coverage starting on January 1. For Medicaid (low income) plans, you can enroll any time throughout the year. If you have coverage through an employer, there is an option of selecting extended coverage when you leave the job (at the employer’s rate plus 2%). And for everyone, there is special enrollment at any time throughout the year if you have a qualifying life event such as a change in residence.

 Check the Math

As premium invoices appear, the bill may not reflect the amount that was quoted. If it seems wrong, call the insurer or broker to make sure your age and smoking status are accurate.

Read your Explanation of Benefit (EOB). An EOB statement is “not a bill” but is important to study. Every service has a procedure code, a billed charge, a contracted rate – varying widely based on where you live. Especially when you have a high deductible or use services not covered by your policy, you need to make sure the amounts are not inflated. You can view your EOBs online or get statements by mail.

 Shop Around

To help lower your out-of-pocket costs, compare prices in your town or other cities. In a non-emergent situation, there are resources and even phone apps to benchmark prices before you get care.

Medicare Fee Schedules from the Center for Medicare and Medicaid Services (CMS). Medicare rates plus a markup are often the basis for reimbursements made by insurers.

—  Healthcare Bluebook

—  Clear Health Costs

—  FAIR Health

Obtaining a detailed bill is important to understand your financial responsibility. There is an industry-wide effort to be more transparent; however specifics are not always easily available. Asking your doctor about money generally isn’t productive. Contacting your physician’s office manager, hospital’s billing department, or an insurance company case manager may be more useful. Patient advocates can assist by locating bills, explaining the nuances of claims, disputing duplicate or incorrect charges, preparing appeals and negotiating payments.

 Stay on Top of the News

What will happen to the Affordable Care Act (Obamacare)? We don’t know yet. In 2017 it’s unlikely to change as the Affordable Care Act remains a national law—and any changes are unlikely to be immediately implemented. Some of the more popular provisions, such as not allowing pre-existing conditions to be part of medical underwriting, may remain intact. All the more reason to stay informed, scrutinize what’s being proposed in any replacement legislation, make your opinion known to your elected members of Congress, and educate and protect yourself by analyzing your health insurance options and understanding what you’re buying.

About the Author

Karen Vogel an insurance expert on the Patient Advocators team. She has two Masters in the healthcare field and has been professionally involved with health education and insurance management for more than three decades. She consults with consumers on health insurance navigation and claims review, and counsels boomers with aging parents. 

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