Health insurance mysteries, explained | CNN

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Whether you opted out of your parent’s health insurance plan or have been openly enrolled for years, health insurance jargon can be difficult to navigate.

Information about the plan’s coverage is not always transparent. The best plan for you depends on your health and needs, so there’s no one right answer, said Renuka Tipirneni, MD, assistant professor of internal medicine at the University of Michigan Medical School.

“It’s confusing to me, I’m someone who focuses on health insurance policies,” Tipirneni said. “But I myself have received a surprise bill. So, I think it’s really important to be aware and then recognize that we all make these honest and easy mistakes, and then reach out for help when it happens.

Not understanding your health insurance can have consequences, including the possibility of facing unexpected or unaffordable expenses, Tipirneni said. If you’re not sure how much you owe, you can avoid getting coverage.

Here are some common mysteries regarding Health insurance, and what you need to know to get the care you need.

Why can’t you enroll in health insurance whenever you want?

“Insurance companies don’t want people to sign up when they get sick,” said John Holahan, an institute fellow at the Urban Institute’s Health Policy Center in Washington, D.C.

“Open enrollment protects the insurance company against what’s called adverse selection — in other words, people choose insurance when they need care, like buying homeowners insurance when your house catches fire,” Holahan said.

Open enrollment periods typically occur between fall and the beginning of winter, Tipirneni said. Generally, you can also enroll during certain life events such as loss of insurance, moving residence, marriage, birth of a child, adoption, or if your household income drops below a certain amount.

If you have a low enough income to qualify for Medicaid — insurance funded by the U.S. government — you can sign up at any time, Tipirneni said.

Some people are confused by the difference between premiums and entitlements. Premiums are the monthly fees you pay to get health insurance—even if you never take advantage of your plan by getting medical treatment. Care or medicine, Tipirneni said.

A claim is the bill a health care provider sends to the insurance company so the company covers part of the health care service, Tipirneni said. Sometimes the provider will require you to submit the claim to the insurance company.

A deduction may seem like a discount, but it’s not. That’s the amount you have to pay out-of-pocket for health care before your insurance coverage kicks in, Tipirneni said.

Discounts usually start in January. If you have a $1,000 deductible for the year, you will have to pay the full cost of any medical treatment until you reach $1,000. One doctor’s visit won’t cost that much, so it could take months to reach the reductions. If you rarely see doctors, you may not reach your deductible before the end of the year.

High-deductible plans are popular because they are often paired with lower monthly premiums. They can look very attractive because they seem to have the lowest upfront cost, but you can Of course it ends up paying more, Tipirneni said. For example, if you have a plan with a $3,000 deductible, but by the end of the year your deductible is not met, you have paid the full costs and monthly premiums for all health care services you received.

“Sometimes it would be a higher total cost than if you had a slightly higher premium and a lower deductible,” Tipirneni said.

If you’re young and healthy and don’t have health conditions or prescription drugs, a high-deductible plan might make sense for you, Tipirneni said. If you have one or more health conditions, expect multiple doctor visits, or are prescribed medications, a plan with a lower deductible may be better.

There is no universal rule for how many expected medications and appointments are needed to qualify for a low-deductible plan—especially since healthy people can have unexpected health needs, such as car accidents or sports injuries.

“All you can do is make your best guess about how much health care you’ll use in the next year,” Tipirneni said.

Once you’ve met your deductible, you’ll usually pay a co-pay with each doctor’s visit — a flat fee that depends on the type of insurance you buy. The remaining bills are usually covered by insurance.

Insurance plans cover different parts of each service, so different copays are available for different services, such as doctor’s visits and treatment appointments, Tipirneni said.

Out-of-pocket costs are an umbrella term for everything you pay besides the premium, Tipirneni said — so, copays, deductibles, coinsurance and more.

Some insurance companies may require you to pay for coinsurance, a percentage of the bill you pay even after your deductible, while the insurer handles the rest.

Some policies have out-of-pocket maximums, which limit your total out-of-pocket costs, Holahan said.

Knowing which services are covered by a plan can be confusing because it can change annually, Tipirneni said.

All plans have a list of covered benefits included in a handbook or other information provided after enrollment, Tipirneni said.

Sometimes plans don’t cover certain conditions or problems you think they do, Holahan said. For example, a plan may cover a hearing test but not hearing aids.

“If you’re not sure, call your health insurance card number to talk to your health plan and ask them how much this is or if it’s covered,” Tipirneni said.

An out-of-network provider does not have a pre-determined agreement with your insurance company about what an out-of-network health care provider can charge for their services.

“If you have doctors and hospitals that really matter, you may want to choose the in-network plan,” Holahan said.

Online provider directories or networks posted by insurance companies can help you see if your current doctor is already in network.

If you have an important prescription drug, check your plan’s drug formulary, which is a list of drugs that are partially or fully covered by insurance. The extent to which a plan covers certain services or drugs may vary, so check each year, Tipirneni said.

She added that insurance plans may cover out-of-network providers to some degree, but typically very little compared to what they cover for in-network providers.

This can be a problem if you need to see a specialist or stay away from home. If you have time before you travel, ask your health insurance company if your destination has network providers or hospitals so you can pay less for unexpected treatments, Tipirneni said.

If you receive an “Explanation of Benefits” statement and aren’t sure what it is, relax—it’s not a bill. It’s just an overview of which parties pay.

If you get a surprise bill — for example, a surgery that involved multiple providers you didn’t know about — Tipirneni recommends appealing the bill to your insurance company or hospital.

“Usually with those conversations, you can lower the amount,” she said. “Some legislation has been passed — and I think hopefully more will come — to try to make it less frequent and make it more transparent so that people make those decisions about where to go for care in a more informed way. are available. .”

If you need more help, Health Insurance Navigators can help you decide which plan is right for you. Health insurance agents can do the same, but they may have an incentive to offer some plans versus others, Tipirneni said.

If you are signing up for government health insurance, you can first talk to the staff who will help you find out if you qualify. The Affordable Care Act website has search functions for finding local help.

If you sign up for work-sponsored health insurance, human resources staff may be able to explain plans or give you materials, Holahan said.

“You can try to do more of your homework when choosing a plan, and if you want to get care, you want to be better informed and set up, and hopefully you’re not paying more,” Tipirneni said.

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