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Whether you’re kicked out of your parents’ health insurance plan or have been running open enrollments for years, navigating health insurance jargon can be daunting.
Information about a plan’s coverage is not always transparent. Nor is there a right answer, since the best plan for you may depend on your health and needs, said Dr. Renuka Tipirneni, assistant professor of internal medicine at the University of Michigan Medical School.
“It is confusing to me and I am a person who focuses on health insurance policy,” said Tipirneni. “But I got a surprise bill myself. So, I think it’s really important to stay informed and then recognize that we’re all going to make these honest and easy mistakes, and then ask for help when that happens.
Not understanding your health insurance can have consequences, including the possibility of facing unexpected or inaccessible costs, Tipirneni said. You may also want to avoid assistance if you are unsure how much you will have to pay.
Here are some common mysteries with regard to health insurance and what to know to get the care you need.
Why can’t you sign up for health insurance whenever you want?
“Insurance companies don’t want people to sign up when they get sick,” said John Holahan, an institute member at the Health Policy Center at the Urban Institute in Washington, DC.
“Open enrollment serves to protect the insurance company against what is called adverse selection, in other words, people who choose insurance just when they need treatment, such as purchasing insurance for children. homeowners when your house is on fire, ”Holahan said.
Open enrollment periods usually occur between fall and early winter, Tipirneni said. Typically, you can also sign up during certain life events such as losing insurance, moving, getting married, having a baby, adopting a baby, or if your family income falls below a certain amount. .
If you have a low enough income to qualify for Medicaid – the US government-funded insurance – you can sign up at any time, Tipirneni said.
Some people are confused by the difference between premiums and claims. Premiums are the monthly fee you have to pay to get health insurance, even if you never take advantage of your plan by getting medicated cures or medications, Tipirneni said.
A claim is the bill that a health care provider sends to the insurance company so that the company will cover its portion of the health service, Tipirneni said. Sometimes the provider will ask you to submit the claim to the insurance company.
A deductible might look like a discount, but it’s not. It’s the amount you have to pay out of your own pocket for health care before the insurance coverage goes into effect, Tipirneni said.
Deductibles usually start in January. If you have a deductible of $ 1,000 for the year, you will have to pay the full cost of all medical care until you reach $ 1,000. A visit to the doctor may not cost much, so it could take months to reach the deductibles. If you rarely see doctors, you may not reach your deductible before the end of the year.
High deductible plans are popular as they are often paired with low monthly premiums. They may look very attractive as they seem to have the lowest upfront cost, but you could they actually end up paying more, Tipirneni said. For example, if you have a $ 3,000 deductible plan but don’t hit your deductible by the end of the year, you’ll have paid the full cost of all health care you received plus monthly premiums.
“Sometimes they will end up being more total out-of-pocket expenses for you than it would have been if you had gotten a slightly higher premium and lower deductible,” Tipirneni said.
If you’re young and healthy and don’t have any health conditions or prescriptions, a higher deductible plan might make sense for you, Tipirneni said. If you have one or more health conditions, expect more doctor visits, or have prescribed medication, a lower deductible plan may be better.
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 unforeseen health needs such as car crashes or sports injuries.
“All you can do is make your best guess of how much health care you will use in the next year,” Tipirneni said.
After reaching the deductible, you will typically pay a ticket with each medical visit, a flat rate determined by the type of insurance you purchase. The rest of the account is usually covered by insurance.
Different services like doctor visits and treatment appointments can have different copays, as insurance plans cover different portions of each service, Tipirneni said.
Direct costs are an umbrella term for anything you pay beyond the premium, Tipirneni said, so copays, deductible, coinsurance, and maybe more.
Some insurance companies may require you to pay coinsurance as well, a percentage of the bill you pay even after you’ve met your deductible, while the insurer takes care of the rest.
Some policies have maximums out of their own pockets, which limit the total expenses you have, Holahan said.
Knowing which services are covered by a plan can be confusing as it can change every year, Tipirneni said.
All plans have a list of covered benefits included in a manual or other information provided upon enrollment, Tipirneni said.
Sometimes the plans don’t cover certain conditions or problems that you think will succeed, Holahan said. For example, a plan might cover a hearing test but not hearing aids.
“If you’re unsure, call the number on your health card to talk to your health plan and ask them how much it will be or if it’s covered,” Tipirneni said.
A networked health care provider has predetermined agreements with your insurance company about how much 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 may want to choose the plan that has them on the net,” Holahan said.
Lists or networks of online providers posted by insurance companies can help you see if your current doctor is already online.
If you have a major prescription drug, check your plan’s drug form, which is the list of drugs that are partially or fully covered by insurance. The extent to which a plan covers certain services or drugs can change, so check it annually, Tipirneni said.
Insurance plans could cover offline providers to some extent, but usually much less than what they will cover for network providers, he added.
This can be a problem if you need to see a specific specialist or are away from home. If you have time before traveling, ask your health insurance company if there are any network providers or hospitals in your destination so you can pay less for any unexpected care, Tipirneni said.
If you get a “benefit explanation” statement and aren’t sure what it is, relax – it’s not an account. It’s just an overview of which parts are paying for what.
If you receive a surprise bill, such as surgery involving multiple vendors, some of which you did not know were offline, Tipirneni recommends that you appeal the bill to your insurance company or hospital.
“Usually with those conversations, you can negotiate the amount down,” he said. “Some laws have been passed – and I think more will come, hopefully – to try to make it happen less often and to make it more transparent so that people can make those decisions about where to go to get care in a more informed way.”
If you need additional help, health insurance navigators can help you determine which plan is right for you. Health insurance agents can do the same, but they may have an incentive to offer some plans over others, Tipirneni said.
If you are signing up for government health insurance, you can speak to the staff who will help you figure out if you are eligible in the first place. The Affordable Care Act website has search functions for local assistance.
If you’re signing up for occupational health insurance, a human resources employee may be able to explain plans or give you materials, Holahan said.
“The more you can try to do your homework ahead of time when choosing a plan, and if you need to be looked after, the better informed and prepared you will be, hopefully you don’t pay more than you should,” Tipirneni said.