Navigating Insurance: The Ins and Outs of Healthcare Costs
AAHANA SHANKARAN –
In today’s day, navigating insurance has started to feel nearly impossible, with legal and medical jargon littering the pages of every major healthcare provider’s websites. And yet, it is also more important now than ever to have access to vital information about how to traverse the dangerous seas of health insurance. Below are some key facts, terms, and tips to understand health insurance and let it work for you.
The first thing to get out of the way is the jargon.
In health insurance, the premium is the monthly cost you pay the insurance company. If the health insurance is covered through your job, the employer may pay most of this monthly premium (covering an average of 83% of the premium for a single plan and 73% for a family plan).
One thing that catches a lot of people off guard is the deductible. This is the amount you have to pay out-of-pocket (meaning you pay it yourself) in a year before your insurance kicks in. For example, if your insurance deductible is $500: that means if you go to the doctor for an MRI, and the bill is $1,500, then you would pay $500 of the bill yourself before the insurance takes into effect. Essentially, it is the patient’s responsibility to pay the deductible amount before insurance is liable for any claims. A health insurance claim is a formal document submitted to your insurance provider from your healthcare provider about the care received and the bill.
Then, after you reach your deductible and the insurance covers the post, you will be paying a copay. A copay is the fixed amount you pay for services covered by your insurance. Similarly, coinsurance is the percentage you pay for services covered by your insurance (both going into effect after your deductible has been covered). Going back to the MRI example: if your deductible was $500, and the bill was $1,500, you would be responsible for covering the $500 deductible in addition to whatever copay/coinsurance is on the insurable $1,000 left of the bill.
There is one thing that prevents you from having to pay obscene amounts of money, if insured. This would be the out-of-pocket maximum (OOPM). This quantity is the maximum you will have to pay in a calendar year towards healthcare costs, including deductibles, copays, and coinsurance. After the out-of-pocket maximum has been hit, your insurance plan will cover 100% of your healthcare costs for the rest of the year.
It is important to remember that the exact numbers for your premiums, deductibles, copays, coinsurance, and OOPMs are dependent on your specific plan. Something that can confuse people is the misunderstanding that these numbers are uniform across insurance providers but they are not. For example, one Aetna plan may have a $500 deductible, whereas another may have a $300 deductible. Thus, it is important to make sure you are inputting your specific insurance card information to get accurate information.
Another common question is: How do you find doctors that accept your insurance? Some healthcare plans can be broad network, while some can be very selective with the doctors they cover. While some doctors’ offices will have information on the insurance they accept on their website, there is a more foolproof way to get this information. Go directly to the insurance site! Almost all insurance plans (including Medicare and Medicaid) have a website that will provide you with a list of doctors in your area that are covered by your specific plan. All that’s needed is your insurance card and access to the internet. Blue Cross Blue Shield, Aetna, Medicare, Medicaid, United Healthcare, Cigna, and Kaiser Permanente all have this feature.
It is also important to know how to appeal an insurance claim. If your claim is denied, it is possible to appeal this decision. The documents you need to appeal an insurance decision and the steps you need to take are all available on the government healthcare website, for internal appeals and external appeals.
This knowledge should be the base level needed to successfully navigate healthcare costs. However, if there is more that you wish to know and understand, if possible, reach out to a patient navigator! Though not in every doctor’s office, patient navigators are readily available in more and more hospitals in America. They are there to aid patients through healthcare costs, insurance, and more. At the University of Georgia’s Health Center, patient navigators are available to discuss these issues with, and reachable by the front desk.
Key Terms: premium (monthly cost), deductible (amount you pay before insurance kicks in), copay (fixed amount for services), coinsurance (percentage you pay after deductible), out-of-pocket maximum (total you’ll pay annually).
Copy Editor- Shriya Garg
Photo Source: https://graduate.rice.edu/news/current-news/navigating-health-insurance-us-basics