Why am I littering your dash with mind-numbing insurance crap?
Because the world of health insurance is complicated, and you can still lose everything if you have coverage and fail to navigate it correctly.
Even if your eyes glaze over instantly at the subject, I suggest you bookmark this as a future reference, because you either have your own insurance now, or you will someday soon, and there isn’t anybody who doesn’t need this knowledge. (Yes, I know there’s a double negative in that sentence. This is a financial post, not a grammar post.)
If you think this is valuable info, I ask you to please share it. You could help somebody save money/sanity.
My cred:
I write health plan docs for a living. I’m an Obamacare expert. I help clients with plan design, so I know the tricks. I implement federal mandates from HHS, IRS, DOL, and state agencies in order to keep my clients legally compliant. I know how to avoid penalties and coverage gaps. I know the tricks of plan design that are implemented to save employers money. I know which laws apply to which types of plans. I know how many ways participants can get severely burned if they don’t know how this works.
1. Your network is everything.
Never visit any type of practitioner without first checking if they are in your network. This is gospel. Many plans have separate INN and OON deductibles and out-of-pocket maximums that do not accumulate together. Some plans have an unlimited OON out-of-pocket limit, so you can still go completely bankrupt if you go OON.
Most plans have network provisions that will cover some OON providers at the INN level: emergency services until you’re stabilized (this is a federal mandate for non-grandfathered plans), No Choice of Provider provision if ancillary services are performed OON (e.g., if an INN physician sends your labs to an OON facility), and various out-of-area provisions. If you don’t know, call the customer service number and ask.
Physicians join & leave networks all the time. Even if your doc isn’t listed in the most recent Provider Directory, it never hurts to ask.
Many plans also have wrap networks that will negotiate with OON providers and facilities, so if all else fails, ask if your plan utilizes one of these to negotiate on your behalf.
2. Understand when your deductible accumulates & resets.
Your deductible is the amount of $ you pay for all services & prescriptions (except mandated preventive care on non-grandfathered plans) before your insurance pays a dime. This is in addition to the $ you pay for your premium. If you’re on an HDHP (high deductible health plan) or CDHP (consumer-driven health plan), your premiums will be very low, but your deductible will be very high. I’m on an HDHP, and my individual deductible is $2,600. Steep.
Deductibles usually reset every January 1, but some plans run off-year. Know your dates. If you’re on an HDHP, use the hell out of the HSA (health savings account) if available.
3. Preventive care is free!! Woohoo!!
The Affordable Care Act mandates certain preventive services be covered with no cost-share.
These lists are updated frequently, and new services are added every few months. My $500 Mirena IUD is now covered 100%, and the deductible is waived. The HPV vaccine is now covered for everybody between age 19-26. Depressing screening is covered. Tobacco cessation, immunizations, STI screening & counseling….all covered.
4. Preventive care isn’t free under every plan! Booo!!!
If your plan is grandfathered, they will likely opt to cover preventive services at the general benefit percent. The deductible will also apply. They are still allowed to exclude any preventive services they want.
Your plan document will (should) state whether your plan is grandfathered or not. If the doc is silent, call the carrier’s customer service line and ask.
5. Assume every EOB/bill you receive has at least 1 error, ESPECIALLY on hospital visits.
For the most part, claims processors have ZERO medical background. They’re paid just above minimum wage and are paid based on how many claims they process per hour. So you can guess how often errors happen.
I just had a preventive OBGYN claim come back as not covered, even though it should have been covered at 100%. If I didn’t know about the PPACA mandate, I would’ve just paid $219 out of my own pocket for an office visit that is supposed to be free.
You are paying enough/too much already for your premiums and deductibles. Make damn sure your claims are being processed and paid correctly. Raise hell if not, and get familiar with the appeals process.
6. Check your Medical Plan Exclusions before you go for any service.
Can’t stress this one enough.
7. Some plans offer surprisingly generous benefits such as 3-D mammography, genetic/genomic testing, acupuncture, and bariatric surgery.
Look at your Schedule of Benefits, but also check your Covered Charges for details on coverage and limitations.
There are federal mandates like the WHCRA, which requires all plans to cover the cost of breast reconstruction after mastectomy. Your plan document should have a section that lists federal notices.
The Mental Health Parity & Addiction Equity Act also requires plans to cover mental health & substance abuse services & facilities at the same level as the medical services & facilities. For example, a plan that covers a skilled nursing facility (medical) must also cover a residential treatment facility (MH). This is a bigger deal than it probably sounds like.
8. Check pre-certification requirements.
This is a cost containment strategy, and a lot of people aren’t even aware that covered charges are often denied/penalized if you don’t obtain pre-cert before the service. Again, check your plan document or call customer service. The most common services requiring pre-cert are: all hospitalizations (excluding routine labor/delivery), surgical procedures, transplants, clinical trials, outpatient rehab therapies, chemo & radiation, speciality drugs, home health care, durable medical equipment, prosthetics, and advanced imaging (MRI/MRA, CT scan, nuclear imaging, etc).
Any penalties you pay for failure to pre-cert won’t apply to your out-of-pocket maximum, so they really super suck. Some plans outright deny all claims for services that aren’t pre-certed.
9. You shouldn’t go broke.
Under PPACA, your in-network out-of-pocket maximum is limited. This means that you will never spend more than that amount in any year forcovered services received from an in-network provider. The key here is the network, which I have to mention again since it is so critical.
Watch your EOBs carefully and monitor your accumulators (deductible and out-of-pocket limit). You can’t rely on the claims processors to get it right. I know it sucks and isn’t fair, but it’s the reality, and it’s your money on the line. There isn’t a claims processor or appeals lawyer in the world who will care more about your money than you do, so it really is up to you to be aware.
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