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Whether you’ve been kicked out of your parents’ health insurance plan or you’ve been doing open enrollment for years, navigating health insurance lingo can be daunting.
Plan coverage information is not always transparent. There’s also no right answer, as the best plan for you may depend on your medical condition and needs, said Dr. Renuka Tipirneni, assistant professor of internal medicine at the College of Medicine. University of Michigan.
“It’s confusing for me, and I’m someone who focuses on health insurance policy,” Tipirneni said. “But I myself received a surprise bill. So I think it’s really important to stay informed and recognize that we’re all going to make these honest, easy mistakes, and then ask for help when it happens.
Not understanding your health insurance can have consequences, including the possibility of being faced with unexpected or unaffordable costs, Tipirneni said. You might even avoid getting treatment if you don’t know how much you’ll have to pay.
Here are some common mysteries As it concerns health insurance and what you need to know to get the care you need.
Why can’t you buy health insurance whenever you want?
“Insurance companies don’t want people to sign up when they get sick,” said John Holahan, a research fellow at the Urban Institute’s Health Policy Center in Washington, DC.
“Open enrollment is intended to protect the insurance company against what is called adverse selection – in other words, people choosing insurance when they need care, such as buying home insurance when your house is on fire,” Holahan said.
Open registration periods typically occur between fall and early winter, Tipirneni said. Typically, you can also enroll during certain life events such as loss of insurance, moving house, marriage, birth, adoption of a child, or if your household income drops. below a certain amount.
If you have low enough income to qualify for Medicaid — insurance funded by the United States government — you can enroll at any time, Tipirneni said.
Some people are confused by the difference between premiums and claims. Premiums are the monthly fees you have to pay to have health insurance – even if you never benefit from your plan by getting medical care care or medication, Tipirneni said.
A claim is the bill that a health care provider sends to the insurance company to cover their share of the health care service, Tipirneni said. Sometimes the provider will ask you to submit the claim to the insurance company.
A deductible may look like a discount, but it is not. This is the amount you have to pay out of pocket for health care before your insurance coverage kicks in, Tipirneni said.
Franchises generally start in January. If you have a $1,000 deductible for the year, you will have to pay the full cost of all medical care until you reach $1,000. A doctor’s visit may not cost that much, so reaching deductibles can take months. If you rarely see doctors, you may not reach the deductible until the end of the year.
High deductible plans are popular because they often come with low monthly premiums. They might look very appealing because they seem to have the lowest initial cost, but you might end up paying more, Tipirneni said. For example, if you have a plan deductible of $3,000 but you do not reach your deductible at the end of the year, you will have paid the full cost of all health care you received plus premiums. monthly.
“Sometimes it will end up costing you more than it would have if you had gotten a slightly higher premium and a lower deductible,” Tipirneni said.
If you’re young and healthy and don’t have any medical conditions or prescriptions, a higher deductible plan might be right for you, Tipirneni said. If you have one or more health conditions, expect multiple doctor visits, or have prescribed medications, a reduced-deductible plan may be preferable.
There is no universal rule as to how many medications and scheduled appointments would require a lower deductible plan, especially since healthy people may have unexpected health needs such as car or sports injuries.
“All you can do is make your best guess at how much healthcare you’ll use in the next year,” Tipirneni said.
Once you’ve reached your deductible, you’ll typically pay a co-payment with each doctor visit – a flat amount determined by the type of insurance you purchase. The rest of the bill is usually covered by insurance.
Different services such as doctor’s visits and therapy appointments can have varying copayments because insurance plans cover different parts of each service, Tipirneni said.
Disbursements are an umbrella term for anything you pay besides the premium, Tipirneni said — so copays, deductible, coinsurance and maybe more.
Some insurance companies may also ask you to pay for coinsurance, a percentage of the bill that you pay even after reaching your deductible, while the insurer handles the rest.
Some policies have out-of-pocket caps, which limit the total out-of-pocket expenses you have, Holahan said.
Knowing which services are covered by a plan can be confusing because it can change every year, Tipirneni said.
All plans have a list of covered benefits that are included in a manual or other information provided during enrollment, Tipirneni said.
Sometimes the plans don’t cover certain conditions or issues that you think they cover, Holahan said. For example, a plan may cover a hearing test, but not hearing aids.
“If you’re not sure, call the number on your health insurance card to speak to your health plan and ask them how much it will cost or if it’s covered,” Tipirneni said.
An in-network healthcare provider has predetermined agreements with your insurance company about what they can charge for their services, while an out-of-network provider has no such contract.
“If there are doctors and hospitals that are really important to you, then you might want to choose the plan that has them networked,” Holahan said.
Online provider directories or networks published by insurance companies can help you see if your current doctor is already part of the network.
If you have a major prescription drug, check your plan’s drug formulary, which is the list of drugs partially or fully covered by insurance. The extent to which a plan covers certain services or medications can change, so check that annually, Tipirneni said.
Insurance schemes can cover off-grid providers to some extent, but usually much less compared to what they will cover for on-grid providers, she added.
This can be a problem if you need to see a specific specialist or if you are away from home. If you have time before you travel, ask your health insurance company if there are in-network healthcare providers or hospitals in your destination so you can pay less for any unexpected care, Tipirneni said.
If you receive an “explanation of benefits” and you’re not sure what it is, relax: it’s not an invoice. This is just an overview of which parties pay what.
If you receive a surprise bill – for example, a surgery involving multiple providers, some of whom you didn’t know were out of network – Tipirneni recommends that you appeal this bill to your insurance company or the hospital.
“Usually with these conversations you can trade the amount down,” she said. “Some laws have been passed – and I think more will hopefully come – to try to make this happen less often and to make it more transparent so that people can make these decisions as to where to go for more informed care. .”
If you need more help, health insurance navigators can help you determine which plan is right for you. Health insurance agents can do the same, but they might have an incentive to offer some plans over others, Tipirneni said.
If you have government health insurance, you can speak with staff members who will help you determine if you are eligible in the first place. The Affordable Care Act website has search functions for local help.
If you sign up for work-provided health insurance, a human resources staff member might be able to explain the plans or give you materials, Holahan said.
“The more you can try to do your upfront homework when choosing a plan, and if you need care, the better informed and prepared you will be, hopefully not paying more than you should be. “, said Tipirneni.