It isn’t. Every health insurance plan is different, so it’s important to check your insurance plan to see what services it covers. You can also review your “Summary of Benefits” which provides you with written information about your plan’s costs and benefits, including preventive services that are now offered to you at no cost. If you have questions about your plan or benefits, you can call the insurance company and ask that a person explain them to you.
Manyplans offer extra programsat little or no cost, such as programs to help you quit smoking, weight loss groups, or support groups for anxiety or depression. You can sign up for these on your health insurance plan’s website, by calling the insurance company, or by asking your doctor for information.
If you have major life changes, such as losing a job, getting a better-paying job, or having a baby, these events can change the amount you need to pay for health insurance. Keep your insurance company up to date about big life changes so you don’t pay more than you should.
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I sympathize with your concern that health insurance may be hard to “use.” Here’s difficult limitations for starters:
- In network providers. Sounds easy enough: choose a provider from an approved list. Gets much harder once your medical provider ceases to be a single doctor.
Just imagine an urgent care visit for a broken toe. You go to an in-network urgent care facility. They will assign you an available physician. The particular physician you get is an independent contractor and may or may not be in your network. The physician wants an x-ray, so he sends you to the in-house imaging facility. Your x-ray will be taken by medical assistants, and the image sent to a radiologist for review. You never get to meet the radiologist and you sure as hell don’t know whether-or-not he is in network. Luckily the toe fracture is uncomplicated. Your attending physician splints the affected toe and gives you a rigid boot to wear.
This simple visit would generate at least 5 separate bills: a facility fee for the urgent care visit, a facility fee for the x-ray, a bill for the boot, a bill from your “attending” urgent care physician and a bill from the radiologist. The facility bills should be in network, the physician bills are a gamble.
- Covered services. What is or is not covered depends less on the service itself and more on an arbitrary standard of what’s “medically necessary.” Yes, your insurance may pay for MRIs in general, but there’s no guarantee that they will pay for the particular MRI your doctor has ordered. You have to go through a process of pre-authorization to find out, which can take several weeks. Weeks during which you cannot receive proper treatment…
- Disagree with a decision made by your insurance company? You can always file an appeal, either directly with the insurance company or with the state insurance department. However, appeals take time. Time you may not have if you are critically ill. Patients have literally died waiting for an appeal to be processed.
Back to the original question. Why is it that health insurance is so not-user-friendly? I would argue that the opaqueness financially benefits every player in the system, except patients needing medical care.
- Physicians can make more money billing as out-of-network providers. Even if only a fraction of the patients will pay the inflated bill, their bottom line is higher than if they accepted the insurance rate. Alas, most patients don’t want to see an out-of-network physician. So physicians need to “trick” patients into thinking they are in network, usually by tagging onto other in-network arrangements. E.g. an out-of-network anesthesiologist working with an in-network surgeon, or an out-of-network physician working at an in-network facility, etc. Facilities let this happen because the medical provider industry has become so consolidated that there’s no real competition left. If everyone does it, patients don’t have a choice.
- Insurance companies can keep rates down by limiting access to high-cost services. Make small stuff (like office visits) easy to access to keep the reputation of your company good, and then deny the infrequent high-cost claims. Occasionally someone may end up suing you, but most people will give up or die before that happens. By keeping your rates down, the insurance product becomes more attractive, enrolls more people and the insurance company has a higher profit margin.
- Facilities want to be as opaque as possible about the cost of their services to keep competition to a minimum. Most facilities don’t want patients to be able to go price comparison-shopping. Then they would have to enter into a bidding war with other providers and they all lose money. The status quo serves the big medical facilities just fine.