One person holds a flashlight revealing a clipboard, Medicare card, money, stethoscope and pills.

Health Insurance in the US - What to Consider

Insurance can be confusing. Recently I have seen posts regarding the high costs related to bladder cancer. I hope that this information will be beneficial to many of you.

For many people in the US, fall is when we become inundated with Medicare insurance plan option information, or we may receive information about health plan options and changes through our employer.

For many, insurance is not always easy to understand as there seem to be changes, additions, and new rules all the time. Take the time to ask questions and know your plan prior to committing to it - I guarantee you will be happy you took the time to become well-informed.

Usual questions you may have

There are a variety of insurance plans in the US. Traditional, PPO, HMO, HSA, Medicare, Medigap, Medicare Advantage, Medicare Supplemental, and Medicaid, to name a few.

Make sure that you clearly understand what your cost is for a premium monthly, the maximum out-of-pocket cost annually that you could be responsible for, and what restrictions, if any, regarding doctors, hospitals, labs, etc.

There are many plans and levels of coverage to understand

Traditional plans have been around for a long time. Usually, there is a set amount or percentage that is covered by insurance for services rendered. PPOs and HMOs may be more limited in some regards.

An HMO, or health maintenance organization, is a plan usually at a lower cost premium with lower out-of-pocket cost, where your primary care physician manages all of your care - this is where referrals come into play. You will generally need a referral to see a specialist. 

A PPO, a preferred provider organization, usually does not require a referral to see a specialist and may have higher costs for the premium and out-of-pocket than an HMO.

HSA, a health savings account, is an option that has not been widely used for as long as the traditional plans but is now more available as a money saver. The premium is less costly for companies as the deductible and out-of-pocket costs are higher before insurance coverage begins to pay. You can put pre-tax money into a bank account to be used to pay for the out-of-pocket expenses. Employers may also contribute to the employee's HSA account, sometimes encouraging this choice for its ability to assist with the costs. This may be a plan to investigate for those who usually have minimal health costs.

Make sure you understand the plans and take the time to investigate each to see which works best for you and your family.

Asking questions is invaluable

Here are a few tips and questions that I like to start with when considering a new plan.

Distinguish the type of coverage

Is the plan traditional? Fully covered? Health saving account? Self-insured?

If Medicare - is it an advantage plan with prescriptions included or a supplemental plan where you may need a different plan for prescriptions?

Does the plan require you to see your primary care doctor for a referral to see a specialist, or are you able to schedule an appointment without a referral?

Consider what you already have going on

Are your usual prescriptions covered, and what amount? Is there a maximum you may pay or a set cost per script?  

Look into options such as GoodRx and SingleCare to reduce prescription costs. Check out other pharmacies, as being loyal to one may not benefit you financially. Sam's Club and Costco also have pharmacies. If you are living with an ostomy and need other supplies, is your preferred provider for DME [durable medical equipment] on the plan?

Your medical providers

Check to see if your medical providers are on the plan you are considering -  doctors, hospitals, labs, dentists.    What is the dental, eye, hearing, and prescription coverage? What is in-network versus out-of-network? Are you covered in an emergency when you travel out of the state, out of the country?

It is best to check with the insurance company and also with your providers to make sure they have the same information. Likewise, you can ask about changes in the new plan year.

The financial responsibility

What is the maximum out-of-pocket that you are responsible for? Understand that a max out-of-pocket is the amount you are responsible for annually should you have high usage. Is that amount affordable to you? How much can and should you put into an HSA? If you are still working, does your employer contribute to that also?

Health insurance is a necessity

Health insurance is a necessity in our lives, but having to change doctors, dentists, and hospitals or having unexpected out-of-pocket costs can be frustrating and stressful.

Make sure you take the time to ask any and all questions that may come up regarding your health insurance coverage. Take notes, and write down the names of those you talk to with the dates to keep a timeline. Attend information meetings regarding your plan options, whether it be at work or for government-funded medical plans like Medicare and Medicaid.

Understanding your health insurance is important

The more informed you are about health insurance and your plan specifically, the less stress you will have when it is time to make use of your coverage. The best plan for one person may not be the best for you. Take the time to find out all you can, and ask questions until you understand the coverage fully.

Finally, make sure you have a copy of the plan document that explains your coverage and your responsibility to costs readily available. Take a picture of your insurance card with your phone, so it is always available whenever you may need it.

I hope this has been helpful. I would love to hear any additional tips or suggestions you may have utilized in making the smartest decision for your insurance coverage. 

By providing your email address, you are agreeing to our Privacy Policy and Terms of Use.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Join the conversation

Please read our rules before commenting.