The biggest health insurance mystery and how to decipher it | CNN

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Whether you’re about to get kicked out of your parent’s health insurance plan or have been on a free plan for years, navigating health insurance jargon can be difficult.

Information about plan coverage is not always transparent. And according to her Renuka Tipirneni, M.D., an assistant professor of internal medicine at the University of Michigan School of Medicine, there’s no one right answer for her, because the best plan depends on your health and needs.

“It’s confusing for me. I’m a health insurance focused person,” Tipiruneni said. “But I got a surprise charge myself. I think it’s very important.”

Not understanding your health insurance can have consequences, including the possibility of facing unexpected or unaffordable costs, Tipirneni said. They may even avoid receiving care if they do not know how much they will have to pay.

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

Why can’t I always get health insurance?

John Holahan, Fellow of the Center for Health Policy at the Urban Institute in Washington, DC, said:

“Open enrollment is meant to protect insurers against what is called adverse selection, which means that when people need care, such as buying homeowners insurance when their house catches fire, It’s about choosing insurance,” Holahan said.

The open registration period typically runs in the fall and early winter, Tipirneni said. You can also typically sign up during certain life events, such as loss of insurance, moving house, marriage, childbirth, adoption, or when household income drops below a certain amount.

If you don’t have enough income to qualify Medicaid — U.S. government-funded insurance — you can get it anytime, says Tipirneni.

Some people are confused about the difference between premiums and benefits. A premium is the monthly fee you must pay to enroll in health insurance. Care or medicine, said Tipirneni.

A claim is a bill sent by a healthcare provider to an insurance company, which covers a portion of the medical services, Tipirneni said. In some cases, your provider may require you to submit a claim to your insurance company.

A deductible may sound like a discount, but it’s not. This is the amount that must be paid out of pocket for medical care before insurance covers it, Tipirneni said.

Deductibles typically start in January. If you have a $1,000 annual deductible, you must pay all medical bills until you reach $1,000. A single doctor visit may not cost much, so it may take months to reach your deductible. There is a possibility.

Plans with higher deductibles are popular because they often come with lower monthly premiums. It may look very attractive because the initial cost seems to be the lowest, For example, if you have a $3,000 deductible plan and don’t meet the deductible by the end of the year, you’ve paid all your medical bills and monthly premiums, Tipirneni said.

“In some cases, the total out-of-pocket costs may be higher than with slightly higher premiums and lower deductibles,” Tipirneni said.

A plan with a higher deductible may make sense if you are young, healthy, and do not have any health conditions or prescriptions. If you anticipate seeing a doctor or are on prescription medication, you may prefer a plan with a lower deductible.

In particular, it is universally accepted that even healthy people may face unforeseen health needs, such as car accidents or sports injuries, so the deductible should be reduced by the expected number of medications or doctor visits. There are no rules.

“All you can do is guess how much health care you’ll be using in the next year,” Tipiruneni said.

After you reach your deductible, you’ll typically have to pay a co-payment each time you visit a doctor. This is a flat fee that depends on the type of insurance you purchase. The rest of the bill is usually covered by insurance.

Insurance plans cover different parts of each service, so different services, such as doctor visits and treatment appointments, can have different out-of-pocket costs, Tipiruneni said.

Out-of-pocket expenses are an umbrella term for everything you pay for other than premiums, Tipirneni said.

Depending on your insurance company, you may also have to pay a premium mutual aidthe percentage of the bill that you pay even after the deductible is reached, with the insurance company taking care of the rest.

Some policies have out-of-pocket limits, which limit total spending, Holahan said.

Knowing which services are covered by a plan can be confusing as it can change from year to year, Tipirneni said.

All plans have a list of eligible benefits included in a handbook or other information provided upon registration, Tipirneni said.

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

“If you’re not sure, call the number on your health insurance card and ask your health insurance how much this will cost or whether it will be covered,” Tipirneni said. .

In-network providers have pre-determined agreements on what insurance companies can charge for their services, while out-of-network providers do not.

“If you have a doctor or hospital that’s really important to you, we recommend choosing a plan that has them in the network,” Holahan said.

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

If you have important prescription drugs, check your plan’s pharmacy, which is a list of drugs that are partially or fully covered by your insurance. Check this annually, as the extent to which the plan covers certain services and medications can change, Tipirneni said.

Insurance plans may cover out-of-network providers to some extent, but they’re usually much less than those that cover in-network providers, she added.

This can be a problem if you need to see a specific specialist or if you are away from home. If you have time before your trip, ask your health insurance company if there are any providers in their network or a hospital at your destination.

If you’ve received a “Benefits Description” statement and don’t know what it is, don’t worry. This is not an invoice. This is just an overview of what parties are paying for what.

If you receive an unexpected bill (for example, a surgery involving multiple providers, some of whom you didn’t know was off network), contact your insurance company or hospital with the bill. We recommend that you request

“Usually in these conversations, you can negotiate a lower amount,” she said. “There were some Bill passed — and hopefully there will be more to come — to make it happen less frequently and be more transparent so people can make more informed decisions about where to source care. It’s for ”

If you need more help, our health insurance navigator can help you decide which plan is right for you. Health insurance agents can do the same, but may have incentives to offer some plans over others, Tipirneni said.

If you have government health insurance, you can speak to a staff member who can help determine if you are eligible in the first place. Affordable Care Act website There is a search function to get local help.

If you have labor insurance, your HR representative may be able to explain your plans and provide you with materials, Holahan said.

“If you can try to do your homework before choosing an insurance plan, you’ll be more informed and you won’t pay more than you need to for medical care if you need it. We can,” says Tipirneni.

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