Although it’s great finally getting health insurance, understanding how it works can be a real pain for the uninitiated. Once you turn age 26, by law you must go off your parents’ plan and enroll in one through your employer, your school or choose one of the new Affordable Care Act plans. Some plans have low premiums but come with a high deductible (the designated amount one must pay before your insurer pays for covered expenses). Whether you are just out of college or grad school or a student at American or Caribbean medical schools, dealing with finding a doctor on your health plan, paying for prescriptions or simply coping with proverbial “red tape” of the insurance industry can be frustrating.
This is the first installment of “Health Insurance for the Young,” a UMHS Pulse series of tips from UMHS staffers for easing the stress of health insurance, from choosing a doctor to understanding copayments, deductibles and coinsurance to indemnity plans and more. To start off, we’ll look at why plan websites can streamline matters when you need a doctor or a script, such as health insurance websites (ones for your plan, not the Obamacare “health exchange” sites that were vilified last year), and what to do if you must make an old-fashioned telephone call to your plan. We’ll give advice on getting a “prior authorization” on prescriptions for which your plan often denies coverage. Finally, we will explain what it means when you receive an e-mail about an “EOB” (Explanation of Benefits) and are prompted to visit your insurance plan’s website.
Answers at Your Fingertips with Health Insurance Plan Websites
Health-insurance plan websites offer a cornucopia of information to members, from which doctors in your area accept the plan (as well as where they went to medical school, completed residency and fellowships) to the plan’s drug formulary (the long list of medication covered, and costs) to status of claims, estimated cost of care for certain procedures, and much more.
Following are some of the benefits of using a health-insurance plan website, based on past experiences of UMHS staffers.
Choose a Primary Care Physician or Find a Specialist Online: Many insurance companies require members to choose a Primary Care Physician (PCP). You’ll save time, in many instances, choosing a PCP online, but always telephone the doctor’s office to confirm that he/she still takes the plan, especially if your insurance company offers different types of plans (such as Oxford/United Health Care “Liberty” or Aetna PPO) because online information could be outdated or updated infrequently. You can also find a specialist (such as an ob-gyn or allergist) by such categories as provider name, city, state, zip code, etc.
Check if Medication is Covered & Cost: All health insurance plans have an online formulary, usually an alphabetized or categorized list of all medications and which “tier” (usually from one to three, indicating the copayment/cost to members) it falls under. If you take any prescription medications regularly, consider using your health plan’s mail-order pharmacy and get a prescription for a 90-day supply from your doctor because the savings can be substantial, and you avoid having to go to the pharmacy for refills every month.
Estimate the Cost for Certain Procedures: The adage “knowledge is power” is certainly true when it comes to health insurance. With many of the better plans, regular doctor visits, blood work and prescriptions only require a small copayment. However, if you need any type of outpatient procedure (for diagnostic purposes, such as x-rays) or are hospitalized, the deductible and coinsurance (a percentage of treatment cost to pay for certain medical costs after your deductible is met) often kick in, so it’s wise to know exactly what you may pay (we’ll explore the benefits of indemnity health plans in a future installment). From mammograms to major surgery, some plan websites give cost estimates based on doctors and hospitals in particular zip codes. However, always confirm costs with the doctor or hospital. A good doctor may have suggestions or give options for lowering the cost of an expensive procedure that your plan may only partially cover (such as local anesthetic or light sedation instead of general anesthesia for some outpatient diagnostic procedures).
Protocol for Telephoning Insurance Companies: Insurance plan websites can provide a lot of great information, but if you have a complex problem or simply don’t understand something, it is always best to actually telephone the company and speak to a representative. The best time to reach most insurance companies is first thing in the morning, around 8 or 9 am, when there are fewer calls and the better trained, most knowledgeable reps are available. Always ask the person’s name and write it down, as well as any claim numbers. If the rep is unable to answer your question satisfactorily, ask to speak to a supervisor/manager, and always remain calm. Yelling and using profanity won’t help at all.
Develop a Good Relationship with Your Pharmacist: Use the same pharmacy to fill all your prescriptions. Since most health care providers now send scripts electronically, using a dedicated pharmacy is essential. Develop a strong working relationship with the managing pharmacist. Why? She/he has the authority to expedite matters when there is a problem with a prescription, such as any medication that requires “prior authorization.” A good pharmacist will take the time to telephone your doctor or nurse practitioner and your insurance company if additional paperwork or information is required to get certain prescriptions filled (forms and paperwork can easily get lost at busy doctors’ offices, so you need a good pharmacist on your side if you ever need an expensive medication). Finally, small, family-run pharmacies or specialty pharmacies (such as ones that stock cancer meds) tend to offer better service and have more extensive supplies of meds than the big chain drug stores.
What is an EOB? Eventually, if you use your health insurance over a period of time, you’ll receive e-mails about an “EOB” (Explanation of Benefits). It is not a bill; it is an explanation of which services and procedures were or were not paid for by your plan. Your insurance company will e-mail you whenever you have an EOB and instruct you to sign into the website to see it. If something was denied, read the reason why carefully, and telephone a plan representative about any medical codes you don’t understand. You can often dispute the insurance company’s denial of payment.
What if You Can’t Afford Your Deductible? Deductibles, the designated amount of anywhere from $500 to $8,000 one must pay before your insurer pays for covered expenses, are inevitable in most health plans nowadays. If you need an outpatient diagnostic procedure or are hospitalized for any reason, the deductible will likely kick in. Depending on how much is owed, some doctors and hospitals will agree to “forgive” part of the cost if you agree to go on an installment plan and make a few months of regular payments. After making payments and showing proof of financial hardship (tax returns and recent paystubs), some doctors/hospitals will then write off the remainder of your debt.
Health Insurance Resources Online
E Health Insurance Buyers' Guide
(Top photo) AT YOUR FINGERTIPS: Health insurance websites help you do everything from find a doctor in your network to estimate costs for certain medical procedures. Photo: Deposit Photos
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Built in the tradition of the best US universities, the University of Medicine and Health Sciencesfocuses on individual student attention, maintaining small class sizes and recruiting high-quality faculty. We call this unique approach, “personalized medical education,” and it’s what has led to our unprecedented 96% student retention rate, and outstanding residency placements across the US and Canada.
Scott is Director of Digital Content & Alumni Communications Liaison at UMHS and editor of the UMHS Endeavour blog. When he's not writing about UMHS students, faculty, events, public health, alumni and UMHS research, he writes and edits Broadway theater reviews for a website he publishes in New York City, StageZine.com.
