Health insurance in the U.S. can be confusing. Many people don't have access to good coverage they can afford, and millions of people don't have any health insurance at all. There are plenty of big picture changes that the federal government needs to make so that health insurance works better.
In the meantime, if you're lucky enough to have health insurance with the system that's in place, you can use your insurance strategically to set yourself up for better health and lower out-of-pocket costs.
Here's how to make good use of your health insurance plan:
Read your plan's coverage documents, every year – even if you think you know what they say
Before you can figure out how to use your plan, you have to know what's in it.
"Many consumers fail to take advantage of the benefits that are offered by their health insurance policy simply because they don't know they exist – or even worse, they end up paying out-of-pocket for expenses that may have been covered," explains Tasha Carter, the Insurance Consumer Advocate for the state of Florida. She helps people understand all kinds of insurance – including health insurance – and her office advocates on behalf of Florida consumers whenever insurance decisions are being made.
Health insurance companies are required to provide a summary of benefits and coverage written in simple language. If you don't get it in the mail at the beginning of the year, you can log on to your health insurance website or call the number on the back of your insurance card and ask for it.
At the start of each year, take a few minutes to look over your summary of benefits, even if you've had the same plan for a long time and you're pretty sure you know what's in it.
"Oftentimes insurance companies also make changes to benefits in terms that are usually applicable upon renewal of the policy, and so you want to make sure that you're reviewing those and you understand what those changes are and how they may impact you," Carter says.
It's also worth checking your benefits if your health has changed recently. Aspects of your plan that didn't matter to you before might now be important, like coverage for specialists or prenatal benefits.
"If consumers can simply make the review of their health insurance policy a traditional practice, it's something that becomes easier and easier to do over time," says Carter.
Find yourself a good primary care doctor
How much you use your health insurance depends on what's going on with your health. An annual physical with your primary care doctor can keep you up-to-date with what's going on in your body, and give you an idea of what kind of health care you might need in the coming year.
Dr. Nicole Rochester works with patients and their families to navigate the healthcare system. She says having a doctor who really knows you – ideally over many years – is really important.
"When you don't have a primary care doctor, you're going sporadically to different providers when you're sick," she says. "They don't know what's normal for you [when it comes to] your vital signs or even your laboratory studies, so all they can do is react in that moment."
A good doctor who knows your family history and your usual vital signs and symptoms. They can help keep you healthy by flagging screenings that you're eligible for, spotting issues before they turn into big concerns and directing you to a specialist if you need one.
Don't have a primary care doctor? Rochester suggests getting referrals from friends or other people you know, instead of relying on internet reviews.
"There's nothing more powerful than talking to a friend, a coworker, a neighbor, a congregation member and asking, 'Do you have a great doctor? Do you like your doctor? What is it you like about your doctor? What is it you don't like?'" she says.
"Just like we utilize our family and friends and colleague network for vacations and hair stylists...we really need to tap into that same powerful network when looking for a physician."
Take advantage of preventive care
Even if you have a bare-bones, high-deductible plan, any screenings or other "preventive" care you need should be included – meaning, you're not responsible for a copay or other out-of-pocket costs.
That includes getting screened for diabetes, cholesterol and blood pressure. "Typically, breast cancer screenings are also free [and] immunizations such as getting the flu shot," says Carter.
The American Academy of Family Physicians periodically updates a handy cheat sheet with recommended screenings by age, although your doctor might recommend something different depending on your personal and family medical history or risk factors.
Plan the timing of procedures strategically
Obviously you can't plan for an emergency appendectomy, but you can be strategic about the timing of planned appointments and procedures.
Health insurance plans come with a deductible amount, which defines the threshold in payments you have to reach before your medical costs are fully covered by your insurance. Depending on your plan, your annual deductible could be a few hundred dollars or it might be as high as $7,000.
On January 1 each year, your deductible resets to zero, which means you're back to paying for your medical care out-of-pocket until you reach that threshold.
If you have a big medical procedure you can plan for, there are a couple of ways to approach scheduling it so that you're maximizing your health care coverage, Rochester says. "Some people will wait until they've met their deductible to get a big procedure," she explains. This could make sense if you don't have a lot of money saved up. If you pay into your deductible with health care services you get over the course of the year and then schedule a surgery for after you've met it, it's more likely your insurance will pay the bulk of the surgery cost and you won't have to pay a big out-of-pocket bill.
Others who have the money up front might choose to schedule a more expensive procedure to meet their deductible early in the year, with the peace of mind that the rest of their healthcare costs that year will be covered by insurance.
Learn how to file a claim
If you see a doctor or go to a clinic that doesn't bill your insurance for you, you may have to pay the whole cost at the time of your appointment and file a claim afterward so that your insurance pays you back for at least part of it.
When you're paying out-of-pocket, ask for an itemized receipt you can use to file an insurance claim. Before you leave the doctor's office, ask them to print one out for you with the information you need, such as the date of service and the diagnosis code.
Then, you'll need an insurance claims form. Rochester suggests calling your insurance company to ask for the right claims form – even if you think you've found it online – just to be sure.
Once you get the correct claims form for your plan, fill out all the information except the signature and date fields, then make copies or scan it. After that, whenever you need to file a claim, all you need to do is sign it, date it and stick it in the mail (or scan and email it) with your itemized receipt you got from your doctor.
In some states, after your insurer gets your claim, they have to process it – and pay you or your provider – within a certain time frame, like 30 days. You can look on your state insurance department website for information about your state's "prompt pay" laws.
Don't miss out on perks
We have to juggle so much just to get – and understand – basic health coverage in the U.S. But despite all of the financial and logistical headaches that come with navigating health insurance in this country, your insurance plan might also come with some nice perks.
Want to take zumba classes? Your insurer might offer discounts if you get a local gym membership. It could also offer discounts on services that improve your quality of life, like LASIK surgery or massages. You might be able to save money on prescription drugs by using your insurer's preferred pharmacy, or by shopping around on your insurer's website for different providers or facilities for the care that you need.
If thinking about your health insurance makes you groan, you're not the only one. But Rochester suggests framing it this way: "Your health insurance plan is a tool for you to maximize your health, but you can only do that if you utilize it fully, and you can only do that if you take the time to explore and to have a clear understanding of your plan and the benefits that it offers."
The podcast portion of this story was produced by Andee Tagle.
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