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Hello lovelies, welcome back, this month I am covering topics related to navigating a chronic illness as three years ago I was diagnosed with Crohn’s Disease. I recently turned 26 and in the United States that means that you get booted off your parents’ health insurance and need to get your own. I also have a unique situation where I’m self-employed, which means that I needed to go through the process of finding and signing up with health insurance on my own rather than having HR at a company do it for me. So as you can imagine I’m a self-proclaimed health insurance expert at this point. Just know I am NOT licensed in health insurance or anything like that so this is just my personal advice and experience and something I wish I had when I was first diagnosed and going on my own insurance.
Hopefully I can make this a little fun and interesting for you – if you’re more of a visual person feel free to hop over to Youtube, I’ll have the link in the description box. I just wanted to get this out on both channels because it’s so important. This one is going to be a little long, but only because I want to make sure I give a good overview.
So to start, I want to give some basics on health insurance terminology and give you an idea of what certain terms mean since here in the US it can get pretty confusing. I imagine it’s similar in other countries, but if you live outside of the US, just know that this is specifically for my experience here in the state of Rhode Island.
Basic terms you should know are Balance Billing, Co-payment, Deductible, Emergency Room Care, Excluded Services, Hospitalization, Hospital Outpatient Care, In-Network, Out of Network, Out of Pocket Limit, Plan, Preauthorization, Preferred Provider, Premium, Specialist, Urgent care. If you want to see more definitions or where I pulled these from, you can visit the link below.
Health insurance is defined as a contract that requires your insurer to pay some or all of your health care costs in exchange for a premium.
Balance billing is When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
A co-payment is a fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
A deductible is The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Emergency room care is what you imagine, emergency services you get in an emergency room, but often have their own specific cost outlined by your health insurance.
Excluded services are health care services that your health insurance or plan doesn’t pay for or cover. This is why you should hold on to your explanation of benefits and don’t be afraid to call customer service on the back of your card to ask if a service is covered. For example, on my dad’s company plan for our family, acupuncture was not covered, but on my new plan, it is covered.
Hospitalization is care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Any services rendered in the hospital are lumped into a total hospital bill. Your health insurance might have a certain amount you’re charged that varies depending on the hospital you go to. For example, I was hospitalized in Boston and Boston hospitals are often more expensive to stay in than Providence hospitals, where I live. I didn’t have to pay the full $30,000 of the cost of staying there for a week though because I have a set deductible and OOP, as any health insurance does.
Hospital outpatient care is care in a hospital that doesn’t require an overnight stay.
In network co-payment refers to a fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
Out of network co-payment refers to a fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co- payments usually are more than in-network co-payments.
Out of Pocket Limit or Max is the most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Your plan is a benefit your employer, union, or other group sponsor provides to you to pay for your health care services. For me and other self-employed people, it is mandatory in Rhode Island to have health insurance. So I went through HealthsourceRI to secure a Blue Cross Blue Shield of Rhode Island plan. Or you can go directly through the insurance company, but I get tax credits through Healthsource because I make a certain amount, meaning I don’t pay the entire plan premium each month.
Preauthorization is a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. For example, every couple of infusions my infusion company needs to contact my doctor to request approval for me to continue my infusion therapy drug at the same amount, and then they send that request to my insurance to verify I still need the medication, because it’s so expensive.
A preferred provider is a provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
A premium is the amount that must be paid for your health insurance or plan. You or your employer usually pay it monthly, quarterly, or yearly. I pay mine monthly through HealthsourceRI, where I get approved for tax credits based on my income.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
Urgent Care is care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Ok for those on the podcast we’re heading into a little commercial break so I’ll pause here.
I know that was a lot of information, so I apologize! I want to put it all into context now for you by sharing my experience signing up with health insurance back in November last year. In August 2022, I knew that I had a few months to choose a health insurance that would best cover me in the new year. Because I have Crohn’s Disease, I have a doctor in Boston who I love and went through an application process to get on her service. I also knew that she was switching from Brigham to Tufts, two hospitals in Boston. (Naturally my unique situation was made even more unique by her transition, but now I feel like there’s nothing I can’t handle when it comes to insurance.) The idea of going through the process of learning about health insurance really scared me and gave me so much anxiety, to the point where I started losing sleep over it. I realized I needed to just take bite-sized chunks out of the process, so I wrote down my to-dos, and scheduled them out over the next few months. However, when I wrote down my to-dos, I realized that because I didn’t know anything about the process, I didn’t know what steps to take. So I called BCBS RI and they let me know they have locations where I can go talk to someone in person about next steps. I made the appointment, and a woman talked me through all the steps I’d need to take, and I realized that it wasn’t as involved or as complicated as I had feared. She even gave me a resource that would help cover the cost of insurance based on my income: Healthsource RI. I believe most states have similar programs, I know Massachusetts has a great one. My next step was making an appointment at Healthsource RI so I could plan for the monthly payments. I found out about how much I’d receive, and which plan I would want to sign up on. Because I know my infusions will set me back a lot because they’re so expensive, I opted for the premium plan with the lowest deductible and OOP limit. While the monthly premium was the most expensive out of all the plans, I know I will only end up paying a certain amount in a year no matter what my insurance covers for my infusions. I also found out my infusions go towards my deductible. Most prescriptions you get at a pharmacy go towards your Out of Pocket amount. You pay the co-pay for the medication when you pick it up, but once you hit the Out of Pocket limit, insurance covers the rest. The OOP is usually more than your deductible. This means that because my infusions go towards my deductible, even if they cost $1000 every time I go, because my deductible is $750, I would pay $750 for the first infusion, and then all my future infusions for 2023 would be completely covered by my insurance. Not ideal for a one time payment, but at least I don’t owe anything down the road.
Something else I consider is the co-pay program I’m enrolled in through my infusion company. Pfizer, the maker of my drug, Inflectra, offer co-pay assistance. My infusion company sends them my insurance information and personal information, and then sends the bill to them and my insurance company before the bill reaches me. This means that both my insurance and Pfizer work to cover as much of my infusions as they can, and then the remaining bill is sent to me and I pay the rest until my deductible is met.
I hope that this episode helps you, and if you’d like to know more about insurance please comment your questions below if you’re on Youtube, or send a DM to lovelydigest on Instagram, or email me at email@example.com
Your assignment is to learn a little more about your insurance, and set up a binder to keep track of your payments and where you’re at with paying your deductible and OOP. I know it’s so easy to just pay the bills and not look at anything else when something is as overwhelming as insurance, especially when you’re dealing with a chronic illness, but learning more about insurance eased my mind and I feel super empowered knowing that I have the perfect plan for me and am paying the lowest amount possible each year. Best of luck and please let me know if this was helpful by leaving a review or commenting below!
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