Health insurance in the United States can be confusing. Many people don’t have access to good coverage that they can afford, and millions of people don’t have any health insurance. There are a lot of important changes the federal government needs to make to make health insurance work better.
In the meantime, if you’re lucky enough to have health insurance with the system in place, you can use your insurance strategically to set yourself up for better health and lower out-of-pocket costs.
Here’s how to make good use of your health insurance plan:
Read your plan’s coverage documents every year, even if you think you know what they say
Before you know how to use your plan, you need to know what’s in it.
“Many consumers miss out on the benefits of their health insurance policy simply because they don’t know they exist – or worse, they end up paying out of pocket for expenses that could have been covered,” Explain Tasha Carter, the insurance consumer advocate for the state of Florida. She helps people understand all kinds of insurance — including health insurance — and her office advocates on behalf of Florida consumers whenever insurance decisions are made.
The sickness funds are required to provide a summary of benefits and coverage written in plain language. If you do not receive it by post at the start of the year, you can log on to your health insurance website or call the number on the back of your insurance card and ask for it.
At the start of each year, take a few minutes to go through your benefit summary, even if you’ve had the same plan for a long time and are pretty sure you know what’s in it.
“Often insurance companies also change benefits in terms that generally apply to policy renewal, so you want to make sure you review them and understand what those changes are and how they may affect you” , Carter said.
It’s also worth checking your benefits if your health has changed recently. Aspects of your plan that weren’t important to you before may now be important, such as specialist coverage or prenatal benefits.
“If consumers can just make reviewing their health insurance policy a traditional practice, it’s something that’s becoming easier and easier to do over time,” says Carter.
Find yourself a good primary care physician
How you use your health insurance depends on your state of health. An annual physical exam with your primary care physician can keep you up to date on what’s going on in your body and give you an idea of the type of health care you may need in the coming year.
Dr. Nicole Rochester works with patients and their families to navigate the healthcare system. She says it’s really important to have a doctor who really knows you – ideally for many years.
“When you don’t have a primary care doctor, you sporadically go to different providers when you’re sick,” she says. “They don’t know what’s normal for you [when it comes to] your vitals or even your lab studies, so all they can do is react to that moment.”
A good doctor who knows your family history and your usual vital signs and symptoms. They can help you stay healthy by flagging the screenings you’re eligible for, spotting problems before they become big problems, and referring you to a specialist if you need one.
You don’t have a doctor? Rochester suggests getting referrals from friends or other people you know, instead of relying on reviews on the Internet.
“There is nothing more powerful than talking to a friend, colleague, neighbor, member of the congregation and asking, ‘Do you have a good doctor? Do you like your doctor? what do you like about your doctor? don’t you like?'” she says.
“Just as we use our family, friends and network of colleagues for vacations and hairdressers…we really need to tap into that same powerful network when looking for a doctor.”
Take advantage of preventive care
Even if you have a simple, high-deductible plan, any screening or other “preventive” care you need should be included – which means that you are not responsible for any copayment or other reimbursable costs.
This includes screening for diabetes, cholesterol and blood pressure. “Generally, breast cancer screenings are also free. [and] vaccinations like getting the flu shot,” Carter says.
The American Academy of Family Physicians periodically updates a practice cheat sheet with recommended screenings by age, although your doctor may recommend something different based on your personal and family medical history or risk factors.
Strategically plan the schedule of proceedings
Obviously, you can’t schedule an emergency appendectomy, but you can be strategic about the timing of scheduled appointments and procedures.
Health insurance plans come with a deductible amount, which defines the threshold of payments you must reach before your medical expenses are fully covered by your insurance. Depending on your plan, your annual deductible could be a few hundred dollars or as high as $7,000.
On January 1 of each year, your deductible is reset, which means that you start paying for your medical care again until you reach this threshold.
If you have a big medical procedure that you can plan for, there are several ways to approach planning to maximize your health care coverage, Rochester says. “Some people will wait until they’ve reached their deductible before undergoing major surgery,” she explains. It might make sense if you don’t have a lot of money saved up. If you pay your deductible with the health care services you get during the year and then schedule surgery after you meet it, it’s more likely that your insurance will pay most of the cost of the surgery. operation and you won’t have to pay a big bill out of pocket.
Others who have the money up front might choose to schedule a more expensive procedure to cover their deductible at the start of the year, with the peace of mind that the rest of their healthcare costs that year will be covered by insurance.
Learn how to file a claim
If you see a doctor or go to a clinic that does not bill your insurance for you, you may have to pay the full fee at the time of your appointment and file a claim afterwards to have your insurance reimburse you at the time of your appointment. less a part. of this one.
When paying out of pocket, ask for an itemized receipt that you can use to file an insurance claim. Before you leave the doctor’s office, have him print one out for you with the information you need, such as the service date and diagnosis code.
Next, you will need an insurance claim form. Rochester suggests calling your insurance company to request the correct claim form — even if you think you found it online — just to be sure.
Once you have received the correct claim form for your plan, fill in all the information except signature and date fields, then make copies or scan it. After that, any time you need to file a claim, all you have to do is sign it, date it, and paste it in the mail (or scan it and email it) with your detailed receipt that you received from your doctor.
In some states, once your insurer receives your claim, they must process it — and pay you or your provider — within a certain time frame, such as 30 days. You can watch on your state insurance department website for more information on your state’s “prompt payment” laws.
Don’t miss the benefits
We have to juggle so much just to get – and understand – basic health coverage in the United States. But for all the financial and logistical headaches that come with navigating health insurance in this country, your insurance plan can also have some nice benefits.
Do you want to take Zumba classes? Your insurer may offer discounts if you get a membership at a local gym. It might also offer discounts on services that improve your quality of life, such as LASIK surgery or massage. You may be able to save money on prescription drugs by using your insurer’s favorite pharmacy or by searching your insurer’s website for different providers or facilities for the care you need.
If thinking about your health insurance makes you groan, you’re not alone. But Rochester suggests phrasing it like this: “Your health insurance plan is a tool that allows you to optimize your health, but you can only do that if you use it fully, and you can only do that if you take the time to explore and get a clear understanding of your plan and the benefits it offers.”
The podcast portion of this story was produced by Andee Tagle.
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