A painful necessity in a democratic society, healthcare insurance policies can be difficult to navigate. Learning more about the options, rights and coverage of your plan can keep you from unconsciously incurring staggering medical bills while you fight colon cancer. Although the majority of tests and treatments are covered by most insurance providers, it's prudent to take a moment and verify this before starting your treatment.
Who Provides Insurance?
There are a few ways to gain access to health insurance as an American citizen. If you're a working adult under the age of 65 you may have access to an employer offered plan or a private insurer. One benefit of using an employer offered plan is that the premiums, or the payments you make for staying enrolled, are usually lower when purchased through your employer (group-rate discount).
If you're over the age of 65, have qualifying disabilities or have end-stage kidney failure, you may have access to the federal health plan called Medicare.
Regardless of your age, if you require financial assistance and are unemployed, you may be eligible for Medicaid, the federal health insurance program for people who require financial assistance.
What Kinds of Plans are Available?
Ranging from the least expensive to the most expensive (typically per premium) insurance plans include:
- Health Maintenance Organizations (HMOs)
- Participating Provider Options (PPOs)
- Consumer Directed Healthcare Plans
HMOs require the selection of a primary care provider (PCP), who directs referrals and out-of-the office tests. HMO plans don't typically have deductibles, but a co-pay may be required for visits or prescriptions.
PPOs allow you to select your own doctors and hospitals. If you select outside of the PPO network, it may cost more. PPOs typically have a deductible.
Consumer directed plans are a type of PPO, but they reduce deductible cost by allowing monies for healthcare expenses to sit in a Health Savings Account, which is tax-free.
Learn About Your Basic Coverage
Each health insurance plan comes with a policy book. This pamphlet explains what coverage – if any -- the insurance company provides for:
- Scheduled doctor's office visits and procedures
- Preventive medicine (screening exams)
- Emergency care
- Hospitalization and surgery
Some specialized plans also include coverage for opthamology (eyes), dental or even for high-risk pregnancies. Check with your provider to see if any of these additional services are covered.
If you frequently travel, consider also asking your provider about out-of-state coverage (or coverage abroad). If you cannot find your policy book, you can either ask your human resources officer for another copy or call the company directly.
Speak to An Actual Person
Don't assume that your insurance covers any procedure, specialist or even preventive screening exams without hearing it (or reading it) first. If you have a procedure or test without getting insurance approval first, there is a good chance you will spend months writing appeals or cover the rejected cost yourself.
Although most doctor's offices and hospitals will check with the insurance company first, it's always prudent to find out for yourself. Depending on your insurance company, the organization may also make case-by-case decisions on select screening exams. For instance, if you have a proven genetic disorder causing colon cancer, some insurance companies will pick up the cost of your screening exams before the age of 50.
What Are My Rights as a Client?
As a client, you have a number of rights that the insurance company must comply with legally. Your rights vary based on your provider and coverage plan (HMO, PPO). Contact your provider if you are unsure of your rights as a client. They may include the right to:
- Accessing emergency care 24 hours a day seven days per week
- Care from your primary physician or a specialist (reasonable access)
- Be informed about your treatment and care plan options prior to making a decision
- Mental health care services
- Substance abuse care and rehabilitation
- Right to appeal any decision that you don't agree with
Contact your provider's customer care line if you feel as though your rights have been violated.
Navigating Medicare and Medicaid
Medicare and Medicaid are federal plans provided by the government, but that is where their similarities end. Medicare offers care for people 65 and older and certain disabled adults with four comprehensive coverage plans (Parts A,B,C,D). Some working adults use Medicare to supplement their current insurance (possibly reducing out-of-pocket cost).
Medicaid is supplied to people of low income or financial assistance. If you are currently receiving Social Security Income benefits you may be eligible for Medicaid.
Centers for Medicare and Medicaid Services. (n.d.). Medicare & You. Accessed May 31, 2012.
Healthcare.gov. (n.d.). Medicaid. Accessed May 31, 2012.
Healthcare.gov. (n.d.). Understanding Insurance. Accessed May 31, 2012.