Understanding Your Insurance Benefits
Terms to Know
Deductible - Amount you pay before your insurance benefits kick in. In some cases appointments are not subject to deductible (ex. annual wellness visits, limited number of mental health visits).
In-Network Provider - A provider who is contracted with an insurance company. When seeing these providers you pay a certain copay - unless your visit is subject to your deductible.
Out-of-Network Provider - A provider who is not contracted with an insurance company. When seeing these providers who pay the full amount up front. If you have out of network benefits you could submit a superbill for reimbursement.
Superbill - A form you can receive from an out-of-network provider to submit for reimbursement. Similar to a receipt for your service. It may include a diagnosis, date of service, type of service, etc.
Coinsurance - The percentage of health care costs you pay after meeting your deductible.
Copay - The amount of the insurances allowed amount you are responsible for.
Allowed Amount - The amount that an insurance will cover/reimburse for a specific service. Depending on your plan, your copay is a part of this allowed amount.
Premium - The amount you pay per month just to have your insurance benefits.
Out-of-Pocket Max - The maximum amount per year you can pay towards any medical service (including copays).
Summary of Benefits and Coverage - A form that can be provided by your insurance that explains the amounts charged and services allowed under your plan.
An Overview
As I am sure you can already tell, there is much to know about health insurance. Why do we pay so much for insurance if we are the ones jumping through hoops to receive care?
The first thing to know about insurance is that it was never intended to help you receive care. Prepaid service plans developed during The Great Depression in order for hospitals and physicians to secure payment for care. Insurance companies want to make money and when you use your insurance benefits, you are costing them money they could have retained.
In order to have access to insurance and in network providers, you pay a premium. If you are employed, your employer may cover part of the cost of the premium. You can generally find the information in any of your employer onboarding documents if you receive insurance through your employer. Different plans will have different premium cost ranges. Catastrophic being the lowest cost and, as it sounds, only covers you in the case you need urgent medical care - all other care being subject to an exorbitant deductible. The other types are bronze, silver, gold, and platinum, for which the premium goes up according to the metal and generally your copay responsibilities, deductibles, etc go down. With a platinum plan you pay the costs up front, meaning a higher monthly cost and low to no cost for medical care.
As the metal grade goes down, insurances want to make sure they get their money/want to ensure they are not paying more than they are receiving from you, so your cost responsibility goes up.
Determining the Plan for You
Much like the insurance companies, we do not want to pay for more than we actually use. When selecting your plan, first take a deep dive into how much medical care you expect to receive.
What’s the easiest way to do this? Review your last year of medical care and please do not rely on your memory. If you do not have access to documents or have appointments in your calendar, log on to your health insurance portal and you can see appointments you have attended.
Take note of the following: your premium, number of primary care visits, number of specialist visits, and any emergency visits. Add the cost of your premiums (monthly premium x 12), primary care copays, specialist copays (be sure to include the amount you paid before hitting your deductible if this applies). This is the total you have spent on health care. Note that in some states your yearly cost of health care may match your yearly cost of rent. Even if you only receive the most basic care.
Next, match your usage with the corresponding plan grade. You never went to the doctor? Maybe catastrophic works - though we should probably talk about that (How much preventative care does the average person need?). You only go for a couple yearly appointments? Maybe bronze is a good call. You’re planning on going for weekly therapy? You need ongoing physical therapy? You have a condition in which you need to regularly see a specialist or have regular blood tests? This is where we start getting to the silver-platinum territory. Compare your current plan with any potential plan you may switch to. Yes. It is so much math and guess work.
Main take away? Do your math.
Getting Your Plan-Specific Information
Everyone should have access to their Summary of Benefits and Coverage. Don’t have it? Log on to your insurance portal, ask your parents (if you are on their insurance), or call your insurance. This form will tell you exactly what to expect.
Some Questions to Ask:
Does your insurance cover X-rays or blood work? (some blood work may be covered and some may be subject to your deductible).
Are you looking for mental health benefits? Does your plan limit sessions? Does your plan allow for out of network benefits?
How much is your deductible? If you meet your deductible are some services subject to a coinsurance?
