Happy New (Calendar) Year!
It’s a new calendar year, and that means many people will have a new health insurance plan. Or last year’s insurance will have been tweaked with a slightly higher deductible or copays, or an updated list of “in-network” providers.
This is a good time to sit down and become familiar with your health insurance benefits, so you aren’t taken by surprise when you actually need to use your insurance. Being sick or injured is awful enough without feeling blindsided by your insurance company.
This is the first year in several years that my health insurance has stayed basically the same: the same deductible (still a whopping $7,000 per person), the same copays and the same prescription drug tiers.
Except the premium has gone up, and my primary care physician decided to leave primary care. So…I have to look through a long list of providers and find a new one. Actually, it’s a pretty short list, because most of the primary care doctors or nurse practitioners have marked their practices as “not taking new patients.” Sigh.
If you are new to health insurance and the basics, check out my two previous posts that explain some of these phrases: premium, deductible, copay, cost sharing, out-of-pocket maximum, in-network, cost sharing, essential health benefits, etc.
Get to know your health insurance plan
Whether you bought health insurance through a health exchange or broker, or you get it from your employer, take a moment to look at your policy and find out the following general information:
- What is the individual/family deductible?
- What is the annual out-of-pocket maximum?
- Does the plan have an HSA (health savings account) or FSA (flexible spending account)
- What is the coinsurance rate?
- Are copays required for primary care visits? Specialist visits?
- How much are the copays?
- Are any primary care visits covered before the deductible is met?
- Is a copay required for emergency room visits?
- How are prescription drugs covered?
- Is there a list of “in-network” providers? This may include not only doctors and hospitals, but pharmacies, physical therapists, ambulance companies and other care providers.
- How is “out-of-network” care covered?
- How is emergency, away-from-home care covered? How is “emergency” defined?
That’s a lot to think about, but I’m not done yet!
Think about your and your family’s specific healthcare needs.
- Do you have any health issues?
- Does anyone take prescription drugs on a regular basis?
- Do you think you need screening tests, such as a mammogram, colonoscopy, or cholesterol level?
- Are you thinking of getting pregnant?
- Do the kids need any vaccinations this year?
- Do you need counseling for depression or other mental health issues?
Then take another look at your coverage. If you seek out care for any of the above, is it really clear to you what is or isn’t covered? In other words, how much you will be expected to pay out of pocket?
- Do you understand the difference between an annual wellness or preventive care visit and an annual physical? (These are NOT necessarily the same thing; check out my post about it here.)
- Is it clear which screening tests and vaccinations are offered without cost sharing (100% coverage)?
- Do any tests, procedures or prescription drugs require preauthorization?
- If you take a prescription drug, where does it fall in the plan’s different tiers of drug coverage? (From generic to costly specialty drug)
Be prepared in case you need to use it
Bottom line, if you need healthcare this year and want to avoid surprise medical bills, it’s worth investing some time early in the year into understanding your health insurance.
If you can’t answer the questions above (and I’m sure you can think of more questions than I’ve listed here!), contact your insurance company or your human resources manager.
And if you have an enormous deductible like me, and you don’t have an HSA or FSA that will cover it, consider setting aside some “just in case” funds. You don’t have to open a separate bank account, but at least give some thought as to how you would pay the deductible if you were suddenly met with a serious accident or illness.
It happens. 😢
For more information on the crazy world of health insurance, here are a few more of my favorite posts:
- Health insurance literacy—it’s not easy
- Do you know your drug formulary?
- Surprise medical bills
- How much does that ambulance ride cost?
- Are Health Care Loans a good idea?
- More find healthcare unaffordable, are underinsured
I’m always happy to answer questions or point you to another source of information. Please leave a comment or use my Contact page.