Understanding the ins and outs of your plan before visiting the doctor can avoid getting stuck paying for treatments, tests and practices out of pocket. “When people start shopping for insurance, they tend to focus on how much they will pay every month,” says Lisa Zamosky, health-care reform expert at WebMD. “What they miss are things like: does my plan limit the number of doctor visits and what is actually being covered?”
Navigating your way through your health coverage can be arduous, but experts offered the following key areas to keep in mind when choosing and reviewing a policy:
1. Wellness Visits Aren’t Always Free
Wellness and prevention are major cornerstones of the Affordable Care Act as a way to reduce long-term care costs. The president’s signature legislation requires all insurance plans to offer consumers access to wellness visits and health screenings free of charge.
But there’s a limit. Whether it’s a colonoscopy, mammogram or wellness visit for a child, there are always rules associated with it, says Zamosky. For example, some plans have age limits for services like a colonoscopy or mammogram to be free.
Some plans also limit the number of wellness visits a year, and confusion of what constitutes a wellness abounds. According to insurance experts, if a person goes to a wellness appointment with a list of complaints about ailments the appointment could be no longer be preventive, but diagnostic, and the patient will be charged accordingly.
2. Beware of Specific Limits, Costs and Deductibles
High-deductible plans, which mean you have to cover any minor or routine health care costs until your deductible is met, are becoming more common.
But it’s not just up-front and out-of-pocket costs you have to pay on these plans. Insured people can be charged for co-insurance and co-pays, all of which may differ depending on the type of doctor you are seeing. For instance, some plans charge higher co-pays when you see a specialist compared to your regular doctor.
Other plans may require a referral before you can see a specialist. “You have to be aware of the specific limits,” says Carrie Mclean, director of customer care at eHealthInsurance. “It’s important to know everything from the co-pay to the co-insurance. Plans can work differently."
You should also know when you need preauthorization for a service in order to have your plan kick in.
“If you have to have surgery, most insurance companies require you to submit paperwork to demonstrate this medically necessary,” says Zamosky. “You have to find out what those rules are.”
It’s also a good idea to bring a list of prescription medicines your insurance covers when you go to the doctors to make sure you aren’t prescribed something you can’t afford.
3. Know Your Doctors
For many people, particularly ones with chronic diseases, they see the same doctors and specialists all the time and are loyal to their care givers. But that loyalty can end up costing a lot of money if one of the doctors falls out of their network.
While it seems like a no brainer, it’s common for people to purchase insurance without first checking to see if their current doctor accepts that plan. It’s not enough to ask a doctor if he or she takes a particular type of insurance, ask about a specific plan. “People really get caught off guard” with this, says Mclean. “Know who your network provider is because if you go out of network, you can get sticker shock.”
4. Read the Summary of Benefits if Nothing Else
Insurance companies make it easy to understand your benefits through a summary of benefits, which includes details of the plan including what is covered before and after the deductible, says Zamosky
It also explains what is covered when you go to the emergency room and other specialists. “It’s an important document to take a look at and refer back to before you go for a service so you know what the rules of engagement are and what you can expect to pay,” says Zamosky.