When I share that I make a living by teaching people how to navigate the health care system, the first comment I hear is "Wow that's so needed, no one seems to understand their health insurance!" Of course right now I am teaching on that topic as seniors have to select their Part B and D insurances in October and in November open enrollment starts for people picking on the Health Exchanges. So I thought I would give you a few key things to think about.
First, health insurance companies are tightly regulated by the federal and state governments. There are certain things they must provide (free annual exams, free mammograms for women over 50, free colonoscopies for everyone over 50, and vaccines are covered 100% for kids). They must also cover hospitalizations, medical testing, physical therapy, sick visits, and medications, but not at 100% coverage. They are required by law to explain how this works (some work primarily on a high deductible, some with co-payments or co-insurance, and some with a combo of both.) They are also obligated to their business plan to not pay for anything they said they wouldn't cover. This often means that extremely expensive or experimental treatments are not covered or that there are limits to the number of treatments they will pay for. It just doesn't matter how sad, desperate, or horrendous your story is, if they don't cover the treatment or all the treatments you need, they don't cover it. They would go bankrupt if they did and then they couldn't cover anyone. It is YOUR obligation to know what your insurer will or will not cover.
Secondly, health insurance is expensive. When you are looking at the cost of your health insurance, you must look at more than just the monthly premium. So you have an understanding in 2010, the average employer paid about $10,000 per employee per year for health insurance. Understanding that should help you understand the costs on the Health Exchange as well. On top of the premium, you may also need to meet a deductible (anywhere from $500 to $3000 per person). Then there will either be a co-payment (a set dollar amount based on the care you are receiving) or co-insurance (a preset percentage of the cost of the treatment ordered). Co-payments and co-insurance will be on medical treatments, doctor's appointments, use of the ER or hospital, and medications. You must estimate how many times you will interact with the healthcare system in order to get an idea of how much it will cost you over the next year. For frequent users of the health care system, or young couples who might have a child, it is often worth it to pay a bigger premium and less in deductibles and co-payments/co-insurances in the long run.
Finally, if you already have a favorite doctor or ongoing medical concerns, you will need to make sure that your health insurance company participates with your doctor and treatment center. Otherwise, you will find yourself having to find a new medical team or paying much higher costs to use a doctor who isn't part of their group. You should also look at any medications you use and check to see what the copays are for those as well. If you have a large family history of cancer, you may want to see if your insurance company will work with some of the large independent cancer treatment centers as well.
As you are going through the different health insurance options out there, here is a list of the words that mean you will have to pay money..... premium, deductible, co-payment, co-insurance, out of pocket, non-participating, not in network, usual and customary charges, non-formulary, and formulary list. Make sure when you see these words, you understand exactly what is being covered and what is going to cost you more.
Hopefully this helps you as you begin to look at health insurance. "I didn't know the speed limit" doesn't get you out of a ticket and "I didn't know that wasn't covered" doesn't make it covered. Go through your health insurance options carefully. Ask questions, of me, at the exchange, at the doctor's office, with your insurance provider. And remember, health insurance was never designed to cover everything but if you read through the policy carefully and you understand everything, it will go a long ways to making your trip through our system a bit easier.
