Martine Ehrenclou, M.A., is a patient advocate and award-winning author of The Take-Charge Patient. Learn more about Martine and her work at thetakechargepatient.com.
Finding out the answers to the following questions will prevent what happens to many of us when we need a medication, test, procedure, surgery, or hospitalization: we find out that our plan doesn’t cover what we need or doesn’t cover the medical provider, hospital, or surgery center of our choice.
Even if you already have health insurance, find out the answers to these questions:
Is my doctor covered by my plan?
Is the hospital or surgery center of my choice covered by my plan?
Is my medication covered by my plan?
Is my doctor, hospital, or surgery center in-network or out-of-network? In-network means lower fees because your insurance plan is contracted with your doctor or hospital. Out-of-network means increased fees since your doctor or hospital is not contracted with your plan. Basically, if you see the doctor of your choice who does not take your health insurance, you will have to pay an out-of-pocket fee and that can be very expensive.
What is my co-pay? A co-pay is the fixed amount you pay for each visit to your medical provider, regardless of whether the visit is covered by your health insurance plan. This is usually about $30.
What is my coinsurance? Once your deductible has been met, you will be responsible for the co-insurance amount, usually a percentage of the bill such as 60/40 or 80/20. This means that your insurance company will pay the higher amount and you pay the lower amount. Not all plans require co-insurance.
What is my deductible? This is the annual dollar amount you must pay first before your health insurance kicks in. For example, if you have a $3,500 deductible, you have to reach that limit before your health insurance kicks in during a calendar year. Each year, you start from zero. Increasing your deductible is the easiest way to lower your premiums, and if you are young and healthy, it could be a good idea. But know that if you have a $5,000 deductible and you get sick, you could end up with $5,000 of medical bills a year before your insurance kicks in. Now that healthcare reform allows for free preventive care, you usually can receive well check-ups for you and your family, immunizations, and screenings for free.
What is my out of pocket maximum? This is the maximum amount of money you pay annually. This is important because it limits the total amount you pay each calendar year.
What is my premium? This is the amount of money you pay into your insurance plan on a regular basis. If you get health insurance from your employer, your premium may be deducted from your paycheck. If you purchase your own health insurance plan, you may have the option of paying your premium annually, quarterly, or monthly.
Regardless of whether you receive Medicare, CHIP, or have private insurance, it is essential to ask questions and become well informed about what your plan covers. Perhaps you believe that you’ll never get sick. Maybe you’re young, healthy, or both. If you aren’t a risk-taker and aren’t willing to gamble on your health, you must have health insurance. Studies show that people who do not have health insurance are generally in poorer health than those who do, avoid getting medical treatment when needed, and generally receive compromised care because they only seek care when they have a serious illness, condition, or injury that forces them to.