We could have a very heated discussion about health benefits in the U.S. right now while we are weathering this pandemic, but I am focusing on the simple, yet never really clear, things about health insurance plans.
If you’re lucky to be on the healthy side and mostly only using your health plan for preventative care (yearly check-ups), you probably don’t normally have to pay when you visit your provider. Likely, they even submit the claim for you (so, it all sort of happens in the background). Maybe you have a small-ish (around $10-$40) copay if it’s a specialist you are seeing (i.e. dermatologist, cardiologist, etc.), but that is a set amount that is often even printed on your insurance card, so little surprise there.
It’s when you wind up in the murky waters of care that involves other types of doctors due to physical or mental health issues outside of regular, preventative care. Suddenly, words like deductibles and coinsurance start being thrown at you and even if you call your health insurance company and speak to someone, the information still seems vague and leaves you crossing your fingers that you understand what you really might be on the hook to pay. Do you know the difference between a copay and coinsurance? They are basically the same thing (the amount you pay out of pocket to see your provider), but one is a fixed rate (copay) and the other is based on a percentage of the billed rate (coinsurance) and goes into effect after you have met your deductible. The key to coinsurance and knowing what you’ll pay is knowing what your provider will charge you. Also, did you know that sometimes the simple question of whether your doctor accepts your health insurance provider’s PPO or HMO plan is all you need to ask to find out if you’re covered in-network or out-of-network for a procedure or not? Hint: they don’t always subscribe to both types of plans (i.e. sometimes they are in-network for an HMO plan, but out-of-network for the PPO plan from the same health insurance provider).
I could write a book on all the information you need to know about health insurance, but I won’t do that here. I do want to highlight a great podcast that I think is helpful in explaining some of the less obvious scenarios, An Arm and a Leg. Dan Weissmann (the show’s host) dives deep into medical care and health insurance, exposing and informing us about the flaws in the system. To me, it’s a podcast about the camaraderie of navigating the current U.S. healthcare system, and often it’s good to know you are not alone with whatever you might be struggling with. You may even find some answers to questions you didn’t even know you have.