New Year, New Health Insurance Deductible

January 5, 2015

It is a new year, time to make and break resolutions. What does your new year hold? Weight loss surgery? Maintaining a healthy lifestyle? Plastic surgery? No matter what is in your future, it is time to check your health insurance policy for any annual changes. Even if you have the same insurance company as last year, it is possible there are policy changes. And if you switched to a new company it is even more important to learn about the policy before that next doctor’s appointment.

Whether your insurance company is new or the same from last year, you should call customer service and review the following (while many companies have information available online it is not always up to date, and if there is a discrepancy and they deny a claim they will say you should have called to verify):

Plan Document/Certificate of Coverage - Request a current copy of your Plan Document (Certificate of Coverage) so you will know all the terms and conditions of the new policy. This will tell you what services and treatments are covered and any exclusions of the plan. Typically this is provided to you by your Human Resources department either in a printed version or online (pdf). This is the contract between the insurance company, your employer, and yourself. *Also request the specific policy related to Treatment of Obesity and/or Plastic and Reconstructive Surgery. These are additional documents from the insurance companies that outline their specific guidelines for coverage.

Insurance ID card — Many companies send out new ID cards every year. Be sure to put the current one in your wallet. However, do not throw away or destroy your old card, you might need the information for any outstanding claims from the previous year.

Doctors — Check to see if your doctors are still participating in your network. Be sure to check your Primary Care Physician(s), and Specialists. You may want to call ahead or fax your new insurance information to your doctor before your appointment so your information is updated when you arrive and you can avoid delays or cancellation. *You may want to cross reference your insurances list of physicians with bariatric professionals and patient reviews on ObesityHelp.com.

Co-pay/Co-Insurance- Co-pay refers to the amount you pay per visit or service. For example, you may owe a $20 co-pay per doctor office visit. Check to see if your co-pays increased from last year. Co-insurance is the percentage of the bill for which you are responsible. For example, if you co-insurance is 70/30, insurance will pay 70% of the bill and you will be responsible for 30%. Your plan could have a combination of co-pays and co-insurance for different types of service.

Deductible - Your deductible is an amount you must contribute before the insurance company will begin payments. For example, if your annual deductible is $500 and a test costs $285 you will be responsible for the entire cost of the test. You need to know what procedures and office visits are associated with the deductible. Do not let yourself be caught off guard by a doctor or hospital asking for your deductible up front. Be prepared.

Out-of-Pocket Max- maximum is the most you will pay annually for your care under your plan. After you have reached the maximum amount, you insurance company will cover 100%. Not all polices have an out-of-pocket maximum, but if yours does and  you are planning major surgery this year, you can plan for your expense.

Continuation of Care - If your treatment for a condition would be interrupted by changes in your insurance you can inquire about Continuation of Care. For example, if a patient had weight loss surgery in December and finds out his/her surgeon is no longer in network as of January 1^st. Follow-up care is medically necessary and he/she may have to wait to be seen by a new surgeon. The patient could inquire with the insurance company and request that they extend network coverage for his/her current surgeon during a transition period.

Visit the ObesityHelp Insurance Forum to ask questions and share information.

ABOUT THE AUTHOR Sarah (aka Sarahlicious) has been an active member of ObesityHelp since 2003. Her specific areas of interests are Lipedema, Lymphedema, Obesity, and Health Insurance advocacy. Sarah writes about her life experiences at Born2lbFat. She is a member of the Board of Directors of both the Obesity Action Coalition and the Lymphedema Advocacy Group. Sarah has a Masters in Health Law. Read more articles by Sarah Bramblette!

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