Understanding the details of your health insurance can often make advanced trigonometry look easy.
But that doesn’t have to be the case, said Khamara Hill, manager of patient financial navigators in Novant Health’s Charlotte and Coastal markets. Here, she breaks down several misconceptions you may have about your health insurance and offers tips for how to better understand what you are – and aren’t – paying.
Sign-ups are now open for the Health Insurance Marketplace, and there are new insurance options available this fall. There are more plans to choose from overall and – beginning next year – some plans will be ending for people who live in certain counties in North Carolina.
Hill’s tips can help you ask smart questions as you review your current plan and decide whether it’s time to update.
1. Many patients think any service they have goes toward their deductible.
This is one of the biggest issues Hill sees: A lot of patients believe that, in the eyes of the insurance company, an ER visit looks the same as an outpatient or inpatient stay at the hospital. The cost of any and every medical service they have goes toward their deductible, right?
Not so, Hill said. And that can be especially hard to stomach for patients with a high deductible.
Hill estimated that the majority of patients understand the difference between copays and coinsurance, out-of-pocket maximums and deductibles. The confusion comes when they try to understand how they all work together.
If you fall into this camp, Hill suggests calling your insurance company. It can clarify what counts toward your deductible – and what doesn’t.
But let’s back up. Feeling befuddled about the terminology? This glossary can help:
- Deductible: How much you have to spend for covered health services before your insurance company pays anything (except free preventive services).
- Copayments and coinsurance: Payments you make each time you get a medical service after reaching your deductible.
- Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.
2. Which providers are in-network, and which aren’t?
This often comes up for medical professionals who patients might not see all the time, like radiologists and anesthesiologists, Hill said.
Her advice – again – is to call your insurance company to clarify. But ask specific questions, she noted. She uses the example of having a baby. If you call your insurance company and ask if your labor and delivery are covered by insurance, they’ll likely say yes, Hill said. But go further. Ask: “Is the delivery of my baby covered? How is it covered? What will I be responsible for in terms of coinsurance? Are there any parts that might not be covered?”
If you’re unsure about what questions to ask about your particular situation, call the Novant Health patient financial navigation team at (888) 277-3901.
3. Don’t give up on an expensive procedure.
Before you undergo any medical service – especially an expensive one – your health care provider should provide you with a good faith estimate for what the service will cost beforehand.
Some patients will come in for a necessary but costly service, like an MRI, and end up canceling rather than undergoing the treatment, Hill said. These patients often have a high deductible, which means they’ll have to pay for almost all of the service out of pocket.
If the cost feels too high, contact your provider for a detailed breakdown of the service, and then call your insurance company. It can often work with you to set up a payment plan or check if you qualify for financial assistance, Hill said.
Want to get an idea of how much your service might cost? Use Novant Health’s cost estimator tool.
4. Secondary insurance coverage won’t always cover your remaining balance.
Some patients are covered under their own health insurance and their spouse’s insurance or other secondary coverage, often called a carve-out plan, Hill said. When this is the case, the patient often thinks they won’t need to pay anything.
But some secondary policies only cover a patient at the same amount as their primary insurance, Hill said.
Her advice here? You guessed it! Call your insurance company. It’s her advice for every conundrum and for a good reason: You won’t get as clear of an understanding from an insurance company’s website or explanation of benefits as you will by calling to talk to a real person. Hill started her career as a customer service representative for Cigna, so she knows firsthand that representatives are knowledgeable people who want to help you.
Pro tip: Take notes when you call. Don’t be shy about asking the rep to repeat details. If you don’t understand what they’re saying, politely ask them to explain again in simple terms. Don’t end the call until you understand what’s being said.
She tells everyone to always check with their insurance company, even her own family.
“My family just calls me,” she said, laughing. But they’re still taking her advice to heart: Call and ask.