How to Shop for Health Insurance
Health insurance isn’t complicated, it’s just something most people haven’t thought about. I spoke with some Russian tourists once and they had no clue what a “hoagie” was. It’s about familiarity more than anything. So, here’s a very brief way to consider health insurance:
The Most Important Thing: Provider Network
What if I told you about a health insurance that covers 100% of the costs? Sounds great right? Well how about if absolutely zero doctors, hospitals, and RX makers work with that health insurance company? Not so good anymore. That’s like me saying, “I’ll give you one trillion Matt Bucks!” Wow… too bad no one in the world accepts Matt Bucks as payment. Same thing with health insurance! Below is a list of the KINDS of networks. After looking up the kind of network, investigate which hospitals & doctors participate IN the network.
PPO = Preferred Provider Organization – You don’t need referrals to see specialists (therapists, dermatologists, etc.) and usually the network is large & national. So, you may be able to go to top tier facilities such as Sloane Kettering in NYC for cancer, Mayo Clinic in Minnesota, or a substance abuse treatment facility in Florida. These plans are typically the most expensive kinds of plans.
HMO = Health Maintenance Organization – You will need a primary care physician (PCP) and referrals to see specialists. The network is usually limited to your geographic area. If you go out of the network, you will have to pay for the entire cost of medical services unless you have prior approval from the insurance company. Certain things like emergency room visits are (sometimes) covered as if you were still in network.
POS = Point of Service – It’s an HMO but with an out of network benefit. The out of network benefit is usually not great… but it is a “back-stop” in case some rare exceptional medical situation happened, and you did want to go out of network for treatment.
EPO = Exclusive Provider Organization – A PPO with no out of network benefit.
Health Insurance Terminology
Out of Pocket Maximum: https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit
Emergency Services: https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/
What Procedures Cost
Discovering what medical procedures cost is VERY difficult. This article was written quite a while ago, but it is still relevant today: BITTER PILL: Why Medical Bills Are Killing Us.
The attitude of most hospitals / providers is, “you don’t need to know that”. Even if you need that information for a claim, they often will not give that to you unless you go through the legal (and confrontational) actions to compel them to do so.
After the procedure is done, you can often look up your “explanation of benefits” (or EOB) to find out what it cost. The EOB is provided to you by your health insurance company and is often available online if you create an account with them.
Before the procedure, it is nearly impossible to get the cost for large procedures. The provider / medical professional wants to charge as much as possible to the insurance company, because most of the time you will only pay a fixed number / copay for that procedure. It will be exceedingly difficult to get a price BEFORE any major medical procedures are done.
Try using sites like these to make sure the price isn’t completely unreasonable: https://www.fairhealthconsumer.org/
How to Find “Good” Medical Professionals
This is subjective and hard to do IMO. Ask around, try people out. Consider direct primary care models and other arrangements as well. Remember, hospitals / doctors are business professionals as well as medical professionals.
Here are a few resources that might be helpful: