image_printPrint Page

Know the Lingo of Your Insurance Plan

Here we are at the start of a new year-the time for new goals and new ambitions. The first of January also marks another “exciting” time- the start of the insurance calendar year, for many. Ah yes- deductibles reset and the possibility of coverage changes— fun stuff (eye roll).

health insurance

I am not an expert on insurance coverage, but there are a few things that I have learned over the years of checking eligibility and benefits for patients that I thought would be helpful to share.

Know your plan and what it covers.

This may seem silly, but the fewer surprises the better. Things happen and pop up and you want to make sure you’re covered for them.

Get to know the lingo. 

  • > Deductible– the amount of money you will have to pay out of pocket before your insurance company chips in
  • > Co-insurance– a percentage of the cost of a visit/service. For example, if your insurance says you have 20% co-insurance that means that you pay 20% of the cost of the service and the insurance plan pays 80%.
  • > Co-pay– a fixed price you pay for certain services. If you have a $15 co-pay for your primary doctor appointment that is all that you are responsible for despite what the actual cost of the visit is.
  • > Out-of-pocket– aside from the deductible there is another bracket of money that is considered your “max out of pocket”. What this means is that the deductible will need to be satisfied first but if that amount is exceeded there is another dollar figure that will be the absolute most the insurance plan will take from you during your plan year. For example, you may have a $1000.00 deductible and a max out-of-pocket of $2,500.00. Once your deductible has been met, there may be other visits/services that they will still collect money from you, but the absolute most they will take during the plan year is what is called your “max out-of-pocket”. Once the out-of-pocket has been met, visits/services should be covered fully. It is good to know what these two amounts are and you can always ask a representative for your accumulations.
  • Covered Services– Spend some time to find out what some of your covered services are. For example, mental health services are generally covered by insurance plans. Others may include smoking cessation, weight loss, and diabetes education/training.
  • > In-Network– are a set of providers and services that are considered within your network of coverage. The only alternative is out-of-network, there is sometimes coverage for those services/providers but they will usually cost more.
  • > Formulary– this is a list of prescription drugs every insurance plan has that is organized into different groups. Groups include low-cost generics, brand-name drugs, another group called “non-preferred brands”, and lastly “specialty drugs”. The official name for this list is “formulary”.  How much you pay depends on which group your medication falls in and this differs from plan to plan.
  • > EOB – stands for Explanation of Benefits. This is not a bill. Your jaw may hit the floor when you read this document, but remember this is not a bill. Consider signing up for the electronic form of this document so you don’t get buried in papers.
  • > Calendar or plan/contract year– an insurance plan either runs on a calendar year from January 1 to December 31 or a contract/plan year which can be any start date that runs 365 days. It is very important to know which one you have. Especially as it pertains to deductible and out-of-pocket accumulations.

Health care professionals can help you generate important questions to ask when it comes time to call your insurance customer service.

For example, going for a CT scan and wondering what your cost will be? Ask a health care professional at your doctor’s office for helpful tips you can ask your insurance plan when you call the member services line to ease you through the phone call.

Get a second opinion.

Believe it or not, sometimes the insurance representative can give you wrong information. Usually, this is not on purpose, but you’d be surprised how often this happens. If something doesn’t sound right ask for the “Team Lead” or simply finish that call and try again. Keep digging for info until you feel satisfied.

Use your benefits.

You pay enough- use them! If you have been diagnosed with diabetes there are several covered options available to you. For instance, I teach a group diabetes self-management education/training class series at a local hospital. It is in-person, but some plans also cover the telehealth option, that we also offer. If this sounds intriguing to you, ask your physician for a referral to Diabetes Self- Management Education. Most insurance plans follow the Medicare standard which is 10 hours of education. For Medicare this is a once-in-a-lifetime benefit; however, two hours of additional education are covered for every calendar year after the initial education is provided. Most commercial and Medicaid plans cover the classes. Also, generally covered, are six visits with a Registered Dietitian annually. Six one-hour visits with an RD at no charge to you. Again- use these benefits!!

If you have questions about your coverage I am happy to help. Insurance is a convoluted spider web. Once you think you have something figured out, something changes. But, the more you get familiar with the ins and outs of your plan the better off you’ll be. The member or customer service number on the back of your card is the best way to get more information. Your plans website is also helpful, specifically the Medical Policy section. It’s not a fun task, but nothing is more frustrating than being blind-sided with a crazy cost. Doing the work now will help you be more prepared, should something unexpected pop up. Again, I am by no means an expert in this field, but I am here to help if you have any questions!

image_printPrint Page