Understanding Your Insurance Plan

by Jane Ashley

For many of us, we’ll have a new health insurance plan in 2019. Even if we stay with the same company, more than likely, there will be changes in our plan that will impact our finances and coverage. Whether we have health insurance through our employer, through the Affordable Healthcare Act, Medicare/Medicare Advantage or Medicaid, the plans are complex and impact our cash expenditures.

So Many Choices

Between now and January 1st, it’s a good idea to look at the details of our 2019 health insurance plan so that we won’t have a nasty surprise when we get our first bills of the year.

Source of your health insurance plan

People are able to get health insurance through different sources, depending on where we work, our income, our age or past military service. 

Even retirees eligible for Medicare have a number of options.

Employer. Every employer in the United States who employs over 50 persons must offer health insurance to their full-time employees. This insurance is often called a group plan or a workplace plan. Many, but not all, employers pay a portion of their employees’ premiums as a benefit. In most cases, employer health insurance will be the most affordable because of their contribution toward your premium.
Marketplace. The Marketplace is part of the Affordable Healthcare Act (ACA) to help people find health insurance. Self-employed individuals and people who work for very small businesses as well as low-income families can use the Marketplace to find health insurance and may qualify for a subsidy to help pay their premiums.
Individual Plans. People who have higher incomes who are not eligible for an employer health plan often purchase their plans on an individual basis.
Medicare. Medicare is for retirees over the age of 65 as well as for people on disability (eligible after two years). Medicare recipients can also choose from a number of Medicare Advantage Plans (which usually include prescription drug coverage).
Medicaid. Medicaid provides health coverage to low-income adults, elderly seniors and disabled persons. Medicaid is administered by each individual state under Federal guidelines.
TRICARE. This is the coverage provided for uniformed service members and their families as well as retirees.

Dictionary of Terms.

Don’t know a copay from an HMO? You’re not alone. Confusion terminology and numerous acronyms prevent many people from understanding exactly what their financial obligations will be should the worst happen.
Co-Insurance. Once the deductible is met, this is the percentage that our insurance pays. Typically, it is 80/20 – the insurance pays 80 percent and we pay the remaining 20 percent. Beware of plans that provide 60/40 … while they offer much cheaper premiums, the insured is stuck with a very large amount to pay.
Copay. This is the amount that patients must pay for a physician’s office visit, an ER visit or prescription drugs.
Covered Person. Anyone who is included on a family plan.
Deductible. This is the amount that you must pay out of pocket before your insurance starts paying. According to the Kaiser Family Foundation, the average individual deductible in 2018 was $1,573. For a family plan, it’s almost $2,788.
Explanation of Benefits. The EOB is an important document that we receive monthly from our insurance company. For each claim in the month, the EOB shows what amount was paid, your calculated copay amount. If part of the claim was denied, a reason will be given.
Formulary. This is the list of drugs our plan will cover. Formularies change from year to year. Check that your current medications are still covered when renewing your plan.
Maximum-out-of-Pocket. This is most that we will have to pay for in-network expenses during the year. For most cancer patients, we’ll reach that max-out-of-pocket quite early in the year. Once this amount is reached, our insurance will cover 100 percent of covered expenses. This is a magical time for cancer patients because we won’t have any more copays for the year.
Preauthorization. This is also known as prior authorization or pre-approval. Certain procedures and medications must receive authorization from our insurance companies. Examples are PET scans and surgery along with some radiation treatments.
Preventive Services. These include screening tests and immunizations that are covered at no expensed to the insured person. Examples include recommended cancer screening tests like mammograms and colonoscopies, flu shots and diabetes screening tests.

Formulary (1)

Types of Plans

The type of plan we select is often influenced where we live and which healthcare facilities we prefer in our area. These plans are the “Alphabet Soup” of healthcare. Here’s how to understand them.
HMO. Known as a Health Management Organization. The HMO requires the patient to select a primary care physician within the network who is their first point of contact. Examples of HMOs are Humana and Kaiser Permanente.
PPO. This is a Preferred Provider Organization. There is a network of physicians and facilities within the network but members can go outside the network at a higher cost.
POS. A Point-of-Service plan requires us to choose a primary care physician. To visit a specialist, you’ll need a referral.

Healthcare Insurance (1)

There are a number of other uncommon plans like High Deductible and Catastrophic and Fee-for-Service but there are only appropriate for individuals and families who have a substantial amount set aside just for healthcare expenses.

The Bottom Line …

Healthcare insurance is complex and expensive, but for those of us who have active cancer and who are cancer survivors, health insurance is critical. Choose carefully and ask lots of questions. Our healthcare insurance is our admission ticket to cancer treatment and surveillance afterward.

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