Open Enrollment — How to Use Your New (and Old) Health Insurance Plan
Healthcare is changing. The industry is trying to offer as wide array of products and services to as many people as possible, while still keeping costs attainable. With prescription drug costs at an all-time high, as an example, this is not an easy task. However, as a consumer there are a few basic steps one can follow, year in and year out, to get the most of your health insurance plan.
1. Understand what is “in network” and what is “out of network.” “In network” means your insurance company has contracted with doctors and/or facilities for discounted rates. Be sure to understand what your co-pay or co-insurance is for both “in network” and “out of network” services or if your plan even covers “out of network” services. When possible, look to your “in network” options for the best coverage.
2. Know whether you need a Primary Care Physician (“PCP”). Some insurance plans require the referral of your designated primary care physician to see a specialist. If possible, while selecting your plan you’ll want to make sure your existing primary care doctor participates in your preferred plan. Health care is built around the patient relationship, and the more time and familiarity a doctor has with you, the better the care they are able to provide.
3. Know what requires pre-authorization. Certain treatments, like surgery, often require pre-approval by your insurance carrier. While your PCP (see #2) can obtain this on your behalf, it is helpful to know what common services may require an additional level of approval.
4. Don’t forget your prescription drug benefits. Most health insurance carriers will have a “drug formulary” that lists which drugs are covered on a preferred basis. If your doctor prescribes a medication, check to make sure it is a preferred drug and if not, explore your options by talking with your doctor or pharmacist. While certain drugs on the formulary may not always be the best price, similar to “in network” services, your health insurance premium gives you access to these often “lower cost” options.
5. Understand your plan rules for co-pays, deductibles and max out of pocket charges. Your costs, in addition to the health insurance premium, will vary from plan to plan and, likely, year to year. Knowing what you are responsible for, often by verifying in advance through your insurance carrier’s member service center, can save you hundreds of dollars annually, if not more.
6. Make sure your doctor visit or service is processed by your health insurance company. Medical billing errors are common. Duplicate charges and incorrect coding results in millions of mistakes each year, so it is important to match the health bill you receive with the Explanation of Benefits (“EOB”) your health insurance carrier provides. Again, this is part of the service you pay for through your health insurance premium. Learn to use it.
7. Keep your insurance card handy and the health insurance carrier member services number on your phone. When in doubt, call. Based on my experience health carrier customer service reps have a lot of inside knowledge and tips. Not sure what you will be responsible for if you make a follow-up visit? Call. It’s unlikely you will use the service often enough to become an expert, so instead make friends with people who are.
So this open enrollment season take a moment to think about how you use the product you are already purchasing, and how to make that experience better. You might find you enjoy the experience more, while also saving money for the other things in your life.
Thanks for reading. Comments and suggestions for other topics welcome.
Below are a few other posts on open enrollment:
Below are a few other posts on health:
And here are my reviews of popular book titles in the health space:
· Dr. Eric Topol’s “The Patient Will See You Now: The Future of Medicine is in Your Hands” here.
· Athenahealth Co-Founder and CEO, Jonathan Bush, “Where Does It Hurt: An Entrepreneur’s Guide to Fixing Health Care” here.
· Dr. Marty Makary’s “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare” here.
HSA Coach. Health is WealthTM