Health Insurance 101

It’s that time of year again – the time when we review our habits over the past several months, look forward to the future and attempt to anticipate what will come, and maybe even call our parents if we deem it necessary.

I’m talking, of course, about open enrollment.

For those of us “fortunate” enough to not receive health insurance from our employers for whatever reason (part time employment, self-employment, working for a small company that doesn’t offer a group plan, etc.), November 1 is a big deal, because that’s the day Obama throws open the doors to the White House and says, “Come, my citizens! Affordable health care shall be yours!”

Or something like that.

Anyway, open enrollment started on Sunday, and if you, like me, get your insurance through the marketplace, this is a pretty big deal, especially this year. Health insurance companies now have enough data to know which plans were “working” (and by “working” I mean “making the most money for them, because there is nothing altruistic about health insurance”) and have responded in kind. If you’re particularly like me, that means you’re losing your health insurance on January 1, 2016, because Blue Cross Blue Shield of Illinois, didn’t like what having a lot of people on its most comprehensive plan did to its bottom line.

Purchasing your own health insurance, especially for the first time, can be an extremely stressful and discouraging process. Companies throw all these foreign words at you–deductible, premium, out-of-pocket, copay, coinsurance, in-network, out-of-network–and if you’ve never dealt with it before, it can be SO confusing. I had to start buying my own health insurance when I was 22 for a variety of weird reasons, and since then have become pretty familiar with the process. So, while this may not be the most exciting topic in the entire world, I think this is really important and wanted to provide a bit of guidance into the thrilling world of health insurance purchasing on the marketplace.

Step One: Terminology Familiarization
Trying to figure out which insurance plan is right for you is a tall order when you don’t understand what most of the words associated with those plans mean. Familiarizing yourself with the technical terminology helps make sense of the differences between plans, and, in turn, can help you get the best value.

HMO: Health Maintenance Organization. Under this type of insurance plan, you are required to select a primary care physician (PCP). You will be required to go through your PCP for just about every kind of healthcare service that exists aside from emergencies (or to an OB-GYN, if you’re a lady). So, let’s say you’re training for a marathon, and you get a pain in your knee that doesn’t go away and you think requires medical attention. Instead of going to an orthopedist, a sports doctor, or a runner’s knee-ologist (<– not a real specialty), you’d go to your PCP. Your PCP would take a look at you and then determine whether or not he/she thought you needed to see a specialist (that is to say, an orthopedist, a sports doctor, a runner’s knee-ologist, etc.). If he/she thinks you do need to see a specialist, he/she will then give you a referral to a specialist that is in your HMO network. If you develop plantar fasciitis a couple weeks later, you’ll go through this same process all over again. If you get a weird pain in your shoulder while sitting at your desk at work, you’ll go through this same process…all. over. again. The idea behind this is that your doctor knows better than you what kind of care you need, and will make appropriate recommendations accordingly, thus preventing you from going to specialists unnecessarily, which insurance companies like, because the less you visit a doctor, the less you use your insurance, and the less they have to spend on you — thus meaning the more profit they make. HMOs tend to have lower monthly premiums than other insurance plans.
PPO: Preferred Provider Organization. Under this type of insurance plan, you can go to any doctor or specialist at any time, but you’ll likely pay substantially more per month.

*a brief pause for my own editorializing*
Personally, I would never mess around with an HMO. I have a primary care physician who I see for approximately 30 minutes per year. Let’s assume my doctor works eight hours per day, and sees patients for 30 minutes at a time every day. If that’s the case, she’s seeing 16 patients per day, or 80 patients per week, or 320 patients per month. Now, while I doubt my doctor actually has that large of a patient load, the fact remains that out of the 525,600 minutes in a year, my doctor spends 30 of them with me at best – that’s .005% of the year. I, on the other hand, spend 100% of my year with myself – and on top of that, I’m the one inside my body, not my doctor. I know my pain or my symptoms in a way my doctor never could, because I’m the one experiencing them. Because of that, I trust myself to know my needs FAR more than I trust my doctor to know my needs, particularly when it comes to whether or not I should see a specialist. If I’m training for a marathon and have knee pain, I don’t want to go to my PCP, who will likely tell me to stop running. (As another aside: if you’re a runner, I would recommend that ALL of your doctors, including your PCP, be runners as well. Most clinics have doctor bios online that include this information. Runners understand runners. Non-runners don’t, as I’m sure MANY of you have experienced when trying to explain why your 10 mile run this morning was short. Having your entire medical team understand your hobby, especially if it’s important to you, can save you a lot of frustration when it comes to injury treatment.) I want to go to my sports doctor, who has an education that allows her to understand my injury better than a general doctor and will likely provide a treatment plan that allows me to continue training. I also want to be able to go to the sports doctor want to go to – not the sports doctor my insurance company tells me I HAVE to go to. If I want a second opinion, I want the freedom to schedule an appointment with a different doctor to get that second opinion. I don’t want to be at the mercy of my insurance plan any more than necessary, and if you have an HMO, you will be at the mercy of your insurance plan to an incredible degree. The money you save upfront won’t mean anything if you have to keep going out-of-network to get the care you desire due to your restrictive–and they are all restrictive–HMO.
*end editorializing*

There are two other kinds of insurance plans as well: Point of Service (POS, hilariously) and Exclusive Provider Option (EPO), but I’ve never seen either one of these on the marketplace. A POS is closer to an HMO, because you need a specialist who will make all your referrals, and an EPO is closer to a PPO, because you get to choose who you see.


Premium: The amount you pay your insurance company per month for access to their services. Depending on your circumstances, you can most likely expect this to be in the ballpark of $100-$350/month. This does not count towards your deductible. The only thing this does is give you insurance coverage.
Copay: A set amount of money you pay per appointment or service. Copay amounts vary wildly by plan, but, in general, you can expect to have a relatively low copay for a primary doctor (maybe $10-$30), a slightly higher copay for a specialist (maybe $40-70), and possibly have copays for other services, like urgent care visits (usually on par with a specialist copay, in the $60 range) or emergency room visits (usually quite expensive, to the tune of $400-$500). Note that this is not the case for all plans, but does tend to be more of the rule than the exception.
Deductible: The amount of money YOU pay before your insurance starts to cover things, kind of. Deductibles vary dramatically from plan to plan. Some plans come with a $0 deductible (these plans generally have a LOT of fine print associated with them, and are HMOs). Some plans come with a $6,000 deductible. Regardless of the amount of your deductible, you can expect to shell out that much money for healthcare services IF the services provided to you 1) are not required to be free, which is the case for a decent amount of preventative care, such as routine vaccinations 2) do not fall into the services covered by your copay. For example: if you go to the doctor because you’re sick, and the doctor orders lab work for you, your copay for your doctor will cover the appointment, but will not cover the cost of the lab work – that will have an additional fee that comes from someone else (and could be possibly be covered by a different copay, depending on your plan, or could not be covered at all).

It is worth noting, however, that if you receive your healthcare services from a in-network provider, your provider almost certainly has negotiated a deal with your insurance company. Going back to that lab work example: let’s say your doctor draws a few vials of your blood, sends them off to a lab, and the lab checks them out to make sure everything’s as it should be. The services the lab provided cost $1,000, and they submit that amount to your insurance company. Because the lab was in-network, however, and has a deal with your insurance company, your insurance company covers half the cost. Assuming you hadn’t met your deductible, you would then get billed for $500, which you would have to pay for out of your own pocket. That $500 will count towards your deductible. The copay you paid to see your doctor in the first place will count as well.
Coinsurance: After you hit your deductible, there’s a decent chance your coinsurance benefits will kick in. With these, your insurance plan will still provide you with in-network discounts (continuing with the lab work example: a $500 discount) and then will cover a substantial portion of the remaining cost as well – but ONLY after you’ve hit your deductible. Let’s say you had hit your deductible before you went to the doctor and had your blood drawn. Your insurance plan states that you have “20% coinsurance after deductible” on lab work. After your discount, your outstanding bill for that lab work was $500, but because you’ve hit your deductible, your insurance will cover 80% of that as well, leaving you to pay 20% (hence, 20% coinsurance. The listed percentage is the amount YOU are responsible for). In this situation, that means you have to pay $100 for your lab work – still a decent sized bill, but substantially cheaper than the $500 you were looking at had you not hit your deductible. This is, I would argue, the most important fine print to watch for when selecting an insurance plan. If you see the term “coinsurance” next to any basic service, proceed with IMMENSE caution, especially if you have a high deductible! I got bit in the butt by not understanding coinsurance in an ENORMOUS way last year, and my deductible was not that high ($1,500). Be very, very wary of coinsurance listed next to any service you could possibly see yourself needing while on your insurance plan. If you’re 25 and see that your plan has a 20% coinsurance on hearing aids, that probably doesn’t need to be a dealbreaker for you. If you’re alive and see that your plan has a 20% coinsurance on primary care physicians, run screaming in the opposite direction. You. Do. Not. Want. That. Plan. 
Network: The providers your plan does or does not cover. If a physician is “in-network,” your standard insurance benefits will apply (low copays, negotiated deals, low coinsurance, etc.). If a physician is “out-of-network,” your benefits will be SIGNIFICANTLY reduced, if they exist at all. Now, of course, your health insurance company isn’t going to arrest you if they find you in the waiting room of a provider who’s out-of-network, but you are quite likely going to have to cover the entire cost of that appointment on your own dime. When I went to a new doctor for a physical in January, the services I received that day–so we’re excluding the shot I was given and the EKG my doctor took–cost $330. Do you want to drop $330 on a 30 minute doctor’s appointment to be told you’re healthy? I sure don’t, and insurance companies bet you don’t, either, which is why they expect you to seek in-network care.
Out-of-Pocket: In addition to having a deductible, every insurance plan comes with a yearly out-of-pocket maximum. This is the total amount you’d have to pay on healthcare all year, excluding monthly premiums (you don’t get any credit for paying your premium – just coverage). If you hit your out-of-pocket max, your insurance company will start paying for everything. Your coinsurance goes away. Your copays go away. ALL of your healthcare is free for the rest of the year — but ONLY for in-network services. If you go out-of-network, you’re still entirely on your own. From what I’ve seen, most plans don’t have an out-of-pocket max for out-of-network services, which means if you go out of network, your insurance company doesn’t care if you rack up $500,000 in healthcare costs: they’re not going to give you a penny of help, because you chose to go out-of-network.

(This is why restrictive networks can be so dangerous. In some cases, it would literally be cheaper to die than seek out-of-network care. If the expert in a field in which you need care is out of network, tough luck, kiddo. You’re going to have to settle for second-class care or hope you win the lottery. Yes, this is horrifyingly unethical. Welcome to the world of health insurance.)

Your insurance company obviously does not want you to hit your out-of-pocket max and have to start picking up the tab on all of your medical bills, as that hurts their bottom line, so your out-of-pocket max is likely to be EXTREMELY high: $3,500-$6,500, I’d estimate. (If you have an extremely high deductible, it may be the same as your out-of-pocket max.). Honestly, if you’re a relatively healthy individual, an out-of-pocket max is more or less irrelevant to you. In 2014, I saw healthcare professionals 60 times: seven doctor’s appointments, one round of lab work, weekly therapy starting in March, twice-weekly physical therapy from June through mid-November, and once-weekly physical therapy from mid-November to Dec. 31. Even with ALL of that service, I didn’t reach my out-of-pocket max (and let me tell you, physical therapy ain’t cheap! Neither is lab work, as those numbers in my example were less “hypothetical numbers I made up” and more “actual numbers I paid.”). If that obscene amount of healthcare didn’t get me to a fairly low out-of-pocket max, I imagine you’d have to have a serious and/or chronic condition to do so (getting into a major car accident, developing cancer, etc.). Your out-of-pocket max is worth keeping in mind when shopping for a plan, but your deductible, premium, and type of plan (HMO vs. PPO) are MUCH more important if you’re a generally healthy person.

Step Two: Self-Examination
There are several important questions you need to ask yourself and honestly answer before you even begin to look at health insurance plans. In no particular order:

  1. Do I currently have any health care providers, and, if so, how do I feel about them? Would I be willing to find a new health care provider if necessary?
    Tip: If you answered “Yes,” and “I like them a lot and am not willing to find new providers,” to this question, you MUST make sure that your current providers accept the plans you’re looking at. This information is almost always available on the insurance company’s website, but you can also call your doctor’s office and ask if you want to be 100% sure. If you’re using open enrollment, wait until after Nov. 1, because by that point, doctor’s offices will know which plans they will accept in the following year. If you don’t have an established relationship with any providers, this is irrelevant (lucky you!).
  2. Do I want to make my own decisions about which specialists I want to see and when I want to see them, or do I want that to be my primary care physician’s responsibility?
    Tip: If YOU want to make your own decisions regarding specialists–specialists being ANY doctor other than a general care doctor or a gynecologist (so we’re talking dermatologists, podiatrists, sports doctors, neurologists, allergists, gastroenterologists–anyone who only focuses on one part of the body or otherwise has a speciality)–then you absolutely want a PPO, and absolutely do NOT want an HMO. If you’d rather leave this decision up to your doctor, both in terms of if you get to see a specialist and which specialist you’re going to see, you may want to consider an HMO. 
  3. Worst case scenario, how much money am I able to spend in total per year on health care?
    Tip: this number probably should not be less than $1,200, because you will likely have an extremely tough time finding a health insurance plan that will cost you less than $1,200 annually on premiums alone, and that doesn’t even begin to include additional costs you may incur. So if you think the most you could afford to spend on healthcare in one year is $3,000 total, you had better look for a plan where the out-of-pocket + 12 times the monthly premium (i.e.: what you’ll pay over the course of the entire year) is equal to or less than $3,000 (good luck with that.). If you can’t find any plans where the out-of-pocket + monthly premium x 12 fits within your budget, then look at the deductible + monthly premium x 12, because that’s MUCH more likely to fit your situation than the out-of-pocket max.
    Tip #2: That being said, DO NOT IGNORE the “worst case scenario” part of this question. I don’t care how young you are. I don’t care how healthy you are. I don’t care if you’ve never so much as gotten a cold in your entire life. No one has ever avoided getting into a car accident because they don’t get the flu. No one has ever avoided a running injury because they haven’t thrown up since they were two years old. Spend a couple nights in the hospital and you could easily rack up a bill that makes your student loans look cheap. You definitely don’t want to have shoddy insurance in that situation.

Step Three: Go shopping.
Armed with all this knowledge, you, young grasshopper, are now prepared to tackle the big, bad world of health insurance purchasing in a way that will allow you to select a plan that fits YOUR needs and YOUR circumstances and YOUR budget the best. When you have a few plans in mind, be sure to pull up their Summaries of Benefits and read them. This is where you’ll find the fine print, and this is ESPECIALLY relevant for us athletes, because this is where you’re most likely to find information on physical therapy coverage, and TRUST ME, you do NOT want to find out the hard way that your plan has lousy physical therapy coverage. Some plans limit the number of PT appointments you can have per year, lumping it in with chiropractic care, which is almost always limited annually. Some plans charge you a coinsurance. What kind of PT coverage you want is a personal choice, but goodness gracious, make sure that you have PT coverage, because if you think a regular doctor is expensive, just WAIT until you get a physical therapy bill. If you’re like me and see a therapist (of the mental, not physical, variety), this is where you’ll find that coverage information as well. If you routinely take prescription medication, be sure to look up those benefits as well.

When you have a few plans in mind, be sure to use the Find a Doctor tool on the health insurance company’s website. Even if you don’t have one particular doctor in mind, do a general search. Your insurance is dead weight to you if it doesn’t cover any doctors in your area. Even more importantly, look up which hospitals each plan covers. Unless you have a comprehensive PPO–which, at least in Illinois, no longer exists for individuals–there will be hospitals that are out-of-network. Going to an out-of-network doctor is expensive. Going to an out-of-network hospital could financially ruin you. In Illinois, the average cost of one night–ONE night–in a hospital if you pay out of pocket is $2,049, and that’s just for the hospital stay. Chances are, you’re only going to end up admitted to a hospital if you really need to be there, and if you really need to be there, you probably aren’t going to be there for just one night. If you spent a week in the hospital, you’re staring down a $14,343 bill at those prices. If you went to an out-of-network doctor seven times and had to pay for all of those appointments, you’re looking at more of a $2,100 bill. Do you want to pay that? Probably not, but given the choice between $2,100 and $14,343, I’m going to go with $2,100 every single time. If you have to pick between in-network doctors and in-network hospitals, always, always, ALWAYS pick the in-network hospital. When shopping for insurance, I would strongly recommend that you don’t even CONSIDER a plan that doesn’t have a hospital close to you that you trust in-network – because again, if you’re going to the hospital, that is the last time you want to risk having sub-par care. In fact, I would even say if your only choices are an HMO with a high deductible that includes a reputable hospital you trust in-network and a PPO with a low deductible with no local hospitals in-network, go with the HMO, because the PPO just would not be worth the risk in my opinion.

Insurance plans vary from state to state, so there’s no one particular plan I could recommend to everyone. You know your medical history and needs better than I do and can choose what will fit your life better than I can. Unfortunately, health insurance companies are not in any way altruistic. They want to provide you with as little coverage as possible for as much as they can squeeze out of you, and they want to have complete control over where you seek medical care, despite the fact that it makes no sense whatsoever for a bunch of Rich Men in Business Suits to decide where you get to go to the doctor (though, as we all learned from the Planned Parenthood situation earlier this year, when has the fact that it makes no sense for Rich Men in Business Suits to meddle in health care actually stopped them from meddling in health care?). Barring a major upheaval in Washington, this isn’t going to change any time soon, and finding a health insurance plan as an individual that actually supports your healthcare needs will become increasingly difficult. While you may not find a perfect plan on the marketplace, knowing what you need can help you work the system a little better, and hopefully save you a lot of financial trouble down the road. Don’t be afraid of supporting smaller companies: they’re the ones who help increase competition for behemoths like Blue Cross Blue Shield, ultimately (hopefully…) driving down costs from other insurers. Good luck!

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6 thoughts on “Health Insurance 101

  1. Thanks. I’m currently “shopping” the market and found your comments right on. The hardest part for me is finding coverage in the hospitals and networks I use and like. The astronomical bill comes after that. 🙂

    • Tell me about it. I was all set with Blue PPO, but since they’re canceling that for individuals, I’m in a bit of a bind. I can either have a network that includes all of my doctors and no hospitals, or a network that includes hospitals but only my PCP (and not my sports doctors, physical therapist, or mental therapist. Though my mental therapist only accepts Blue PPO anyway, so I wasn’t going to be able to find coverage for her, anyway. Hmph.).

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