Health insurance provides us with a sense of security. We believe it equips us financially to manage health issues from minor to major medical emergencies. But does insurance really secure and protect us? If you don't know the extent of your medical coverage or your financial obligations, then your sense of protection regarding medical preparedness could be misplaced. You owe it to yourself, your health, and financial well-being to know exactly where you stand with your health insurance. Actually, it's your responsibility to know and understand your health insurance policy because you should know what to expect and perhaps even demand what to receive.

Insurance Basics

Having health insurance is not the same as coverage. There are numerous insurance companies, and each offers different types of policies which result in a diversity of coverage limits and costs. Familiarizing yourself with the way your policy works enables you to know the extent and cost of care you, or a family member, are entitled to receive. Also, keep in mind that your insurance policy is a contractual agreement between you and the insurer. If you're looking for help from anyone to decipher coverage and costs, don't just turn to the insurance company, but, contact your insurance agent or human resources representative (if you are insured through your employer) to answer your questions. If you need immediate or further assistance understanding your health insurance and financial obligations, then a health advocate could be instrumental in helping you.

Plan Options

The cost of a health insurance policy (i.e., monthly premium) might be the primary criteria that most people use when selecting coverage. Rather than evaluate insurance on its premium fee, instead, it is more sensible to consider the type of health insurance plan you have when evaluating your policy, as well. Plans vary in scope of coverage and flexibility:

  • HMO – Health Maintenance Organization. A good plan if you're looking for lower out-of-pocket expenses, but little flexibility in the choices of doctors or medical facilities due to limited networks. Selecting a Primary Care Physician (PCP) is required and will issue a referral to a specialist when necessary. There are no benefits for services provided by an out-of-network provider.
  • PPO – Preferred Provider Organization. This plan offers greater flexibility with selecting physicians, and a PCP is not required. Referrals from a physician for a specialist are not required, but some services may require pre-authorization. Doctors, hospitals, and other providers in the plan's preferred provider list must be utilized in order to take advantage of the lower negotiated rates between insurer and provider.
  • EPO – Exclusive Provider Organization. A combination of HMO and PPO. Like a PPO, doctors are selected from a preferred providers list, and referrals to a specialist are not required. However, there are no benefits for services provided by an out-of-network provider.

Plan Coverage

Next, take a look at your plan to assess whether it meets your personal and family needs. You might already know what type of health insurance plan you have, but if you don't, take a look at your insurance card for a quick reference. Hopefully, you have a copy of your health insurance policy so you can review your Summary of Benefits. The information in the summary serves as a quick reference guide about your coverage. This summary differs from the Policy Booklet, which is an extensive and detailed explanation of the policy.

The Summary of Benefits presents the scope of coverage concisely and is a useful reference if you want to compare your plan with another one. You'll be able to assess whether your needs will be met. However, before you start reviewing your plan, you might want to know some key insurance terms:

  • In-Network vs. Out-of-Network:

In-Network: Doctors and hospitals included in a preferred provider list approved by the insurer. These "preferred providers" have negotiated rates, or "allowed amounts," which provides the insured a discount on covered services.  

Fees for Out-of-Network: Physicians, facilities, or services are not subject to the negotiated allowed amount rates, which can cost you sustainably more.

  • Referral vs. Pre-authorization: 

Referrals are provided by a primary care doctor (PCP) to an in-network specialist that will continue care for a specific condition, and insurance company approval is required.

Pre-authorizations are for specific procedures, treatments, or services which may require pre-approval from the insurance company in order to be covered.

  • ACA vs. Non-ACA Coverage:

The Affordable Care Act (ACA), derogatorily referred to as Obamacare Plans, cannot deny coverage based on pre-existing conditions. Which means major pre-existing conditions like diabetes, heart disease/stroke, cancer, COPD, or HIV must be covered under these plans. However, non-ACA plans can and will deny coverage for pre-existing conditions.

The odds of finding one perfect plan for you and your family are not likely. Although it is possible to find a plan that best suits your existing needs, it just takes a little time and research to choose a plan that satisfies cost, coverage, and flexibility. PPOs are good if you prefer the most flexibility, and an HMO or EPO can save you some money on costs. The goal is to assess your specific needs and preferences, then select a policy that is right for your situation.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very highly reviewed entity and accredited by the Better Business Bureau with an A+ rating. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB's), reach out…..get help… one of our Board-Certified Patient Advocates. We review medical bills and health insurance determinations to locate errors in providers' charges and insurer's processing. We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!