Understanding Health Insurance

The USA health insurance system is confusing. This is a practical guide to understanding health insurance from the perspective of a young professional. I explain common healthcare definitions and pricing, acronyms and plans. I also include the process and script I use to make healthcare appointments.

Definitions

This is a short list of common terms I see when looking at my insurance. This is useful for calculating how much you're expected to pay for healthcare services. Even with insurance, healthcare can be expensive.

• Premium: How much does your health insurance cost? This is the amount paid for healthcare coverage, not any healthcare services. If you're covered through an employer, they'll often pay this amount.
• Deductible: The amount of money you have to pay out of pocket before insurance starts covering your expenses. For example, if you have a procedure for $200 and your deductible is $50, then you have to pay $50, and insurance can help cover the other $150. If you have a procedure for $40 and your deductible is $50, then you have to pay $40.
• Co-insurance: The percentage of the service cost you pay out of pocket. For example, suppose you have a procedure for $200, your deductible is $50, and your co-insurance is 20%. You have to pay the $50 deductible + 20% of the other $150 ($30), so you'd pay $80.
• Co-pay: The amount of money you have to pay out of pocket for doctor visits. For example, my vision plan has a $10 co-pay for eye exams, so I paid $10 for an eye exam.
• Maximum coverage: The maximum amount your insurance will pay for you in a year. After that, you have to pay out of pocket.
• Out of Pocket Maximum: The maximum amount of money you have to spend on medical care before your insurance covers 100% of your expenses.
• Allowed Amount: This is a negotiated rate between the health plan and the plan's in-network providers. The in-network providers agree to not charge more than the allowed amount to members of the health plan. Out-of-network providers can charge what they want. This is part of the reason why in-network providers are cheaper.

Acronyms

There are many types of health insurance plans. You may see the acronyms HMO, PPO, EPO, and POS. I'd suggest this article to explain the difference. More practically, how do you pick an insurance plan?

If you're in good health and paying for health insurance out of pocket, you can optimize for a cheaper plan (lower premium). When picking health insurance plans from an employer, you can ask the HR team or other employees in a similar stage of life to you. If you're don't need a lot of medical services, one rule of thumb is to favor the plan with the highest premium to the employer at no additional cost to you.

An employer may also offer you an FSA (a Flexible Spending Account). You can put money in this account to pay for assorted healthcare expenses. This includes doctor visits and assorted healthcare objects, such as bandages, sunscreen, allergy medicine, glasses, and painkillers.

The advantage is that you don't pay taxes on this money. That means if you put $1000 in the account and would've paid 20% in income taxes, then you'd save 20% * $1000 = $200. However, you can't get the money back. If you don't use all the funds in a year, some funds can roll over to the next year, and some plans include a grace period (extra time to use the funds). If you still have unused FSA funds, they go to your employer.

Making an Appointment

This is the process and scripts I use for making healthcare appointments.

Find relevant documents

First, find out what insurance plans you have. I have separate plans for healthcare, vision, and dental, so I need to provide different insurance information depending on what healthcare service I need. I find this information through Zenefits, a type of HR software.

In terms of documents, find your insurance card, a valid ID, and a payment method. The insurance card has a bunch of numbers that you'll need to tell the doctor. I got physical copies of my insurance cards in the mail, but virtual versions are also available on the healthcare plan's website. You'll need the ID and payment method later when you go to the doctor.

Who do I contact?

I start by searching for in-network providers near me via the healthcare plan website. In-network providers are cheaper, so that's why I search on the plan website first. Healthcare plan websites are usually clunky, but eventually give you a list of doctors, office locations, and phone numbers.

To filter the list, I sort by location to find doctors that are close to home or work. I also cross-reference review sites (e.g. Yelp, Google reviews) to see if a place has awful reviews. If it has 2-3 stars, I won't bother contacting them. A lot of doctors don't have reviews, so a lack of reviews doesn't deter me.

Sometimes the search also gives you emails or doctor websites. Most doctors don't accept online appointments, so you need to call during business hours. Business hours vary, but you can aim for Monday - Friday 9 AM to 5 PM. You can also email, but they'll probably tell you to make a phone call.

Phone Call Script

This is the script I use when calling doctors. I like to write this down for reference before making a call. Make sure you have your insurance card available. Tweak anything in brackets according to your needs. For instance, a [procedure] can refer to any health care procedure such as a check-up, eye exam, or dental cleaning.

• Call a doctor during business hours.
• Tell them `Hi. This is [your name]. I'm looking to get a [procedure] in the next 2 weeks. I have health insurance under my employer: [employer name], [name of health plan]. [Are you accepting new patients?] Do you have appointment availability soon?`
• If you don't know what procedure you need, you can ask for an appointment and briefly describe your problem e.g. `My [body part] hurts.`
• If they aren't available, and you're leaving voice mail, add `You can call me back at [your number].`
• If they have trouble spelling your name, spell it out for them using a phonetic alphabet. You don't have to memorize the official phonetic alphabet, and you can just make up words. For example, I often say `My last name is L as in lion, I as in ice cream, and N as in Nancy.`

Conclusion

I hope this helped explain how to navigate the messed up USA health insurance system so you can find affordable healthcare.