Millions of people have selected insurance plans for 2024
but sometimes navigating them can be tricky time consuming
and expensive.
So joining me now to break down what we need
to know is the host of Afford Anything podcast,
Paula Pans, Paula.
Welcome back to the show. Thank you. Thank you so much for having me here.
We're so happy to have you.
So for those who might have selected plans for
2024 what should they be paying extra attention?
So there are four things that in any given year
people should always be paying attention to your deductible,
your copay, your co insurance and
your annual out of pocket maximum.
Now,
let's break down what those are your deductible is the amount of
money that you're going to pay first before your insurance starts paying
your copay is think of it like a cover charge.
Like if you're going to see a band perform, that's the six
amount of money that you pay for prescriptions
for outpatient care for things like that.
Your co insurance is the percentage split
that between you and your insurance company,
what you pay versus what they pay
and your annual out of pocket pocket maximum is the cap or limit
to the amount that you're going to pay in a given plan year?
Ok. All very good. And we were chatting before the show started.
I wish I learned this right growing
up.
But it's good that we're learning now.
Right. Better late than never. It's incredible that this is not taught. I
know it's so important.
Well, we're covering it on the show. So that's the good news.
Is there a way to check which providers? Right?
Because some people might have providers that they,
they worked very closely with which ones are in and out of network as the year turns.
That is such an important question. I'm glad that you asked it. So
if a provider is in network,
that means that they have negotiated with your insurance company
for a reduced rate that you,
that the provider will accept as payment in full.
If they're out of network,
then they don't have a contract with your insurance company.
Now, what that means for you is that if a provider is out of network,
that means you're going to be paying more money as for how much more
it depends on the type of plan you have.
But in the worst case, there are some plans that have zero out of network coverage.
Zero, Zilch
Nada, you're on the hook for the whole thing
I was just going to ask, right.
If there was any way whatsoever to get reimbursed
for some of those out of network providers.
No, first in some plans, zero, it completely depends on the terms of your plan.
So check the terms, but in the worst case,
you know, some plans will pay a little bit, some plans will pay nothing.
Now, there are three ways that you can check.
One is on the insurance company website.
You can go to the website for your insurance company and look
at what plans uh what providers are within their plan network.
So you can
check the website of your insurance company.
Um Conversely, if there's a particular provider that you really like a hospital,
a clinic, a doctor that you really like,
you can check their website to see whether or
not your insurance company is in network for them.
The third option is to go to a third party platform, something like Zoc
Doc
where you can search based on uh
in
ok, very good to know. Now some doctors, especially specialists, surgeons,
people of that nature, doctors of that nature, they might have multiple locations.
Should you assume that you are covered?
Your plan covers that doctor at different locations?
No, in fact, you should never assume anything because actually
here's, here's where it gets even worse.
Sometimes
you might be
at an in network facility,
but there might be, they might be contracted with a provider who is out of network.
So for example, let's say that you twist your ankle, you go to the emergency room,
right, the hospital that you're at is in network,
but they might have an anesthesiologist or,
or a radiologist who they've contracted with, who is out of network.
And so then you get a surprise bill. Now, there was a,
a
law that went into effect on January 1st 2022
called the No Surprises Act,
which is meant to reduce or eliminate those types of surprises where you think
that you're getting in network coverage and
you're actually getting out of network coverage.
But because that law went into effect relatively recently,
it's something that you want to be very alert for.
So the bottom line is never assume anything.
So what if you are surprised?
Right? What if you, you call your doctor's office?
They say that they're in network, you check their website, they in network,
they seem to be a network based on your plan.
You see them at a location
where that location is in network, but they are out of location
at that particular location. How do you navigate a
bill
that would come for out of network coverage in that case?
Well, the,
the primary thing you want to do is check your bill for any type of
errors because it might be if you've gone
through the due diligence of contacting your,
like making sure that you are getting
in network care,
it might be that they have simply misco
your bill.
So when you're looking at the bill, you want to check something called AC PT code
and match those CPT codes with the type of uh
service that you got to make sure that you have,
you are being billed for what you have.
You also want to compare all of this
against what's written on your explanation of benefits or your EOB.
Ok. Very good to know.
And now there are a whole host of different plans not to make it more complicated,
but it's the reality.
Right. So we've got hmoppop Os, right? Sometimes even a premier network. Right.
Right. What do people need to know about the differences between these? Sure.
So when HMO is a health maintenance organization
and it is an organization that has a closed
or restricted list of providers that they will accept.
I see a PPO by contrast is a Preferred Provider organization.
What that means is, is our preferred provider organizations.
That means it's a network of different providers, um, who you can go to
and then, uh P OS is,
uh, point of service. It's a bit of a hybrid between the two.
Now, the main thing that you need to know is whether for you, for your purposes,
whether something is in network versus out of network,
and you also need to know whether you need a referral or not.
Ah, ok. Very good.
And, uh, these are questions you should be asking up front. Yes.
If you need a referral, you'll get that from your primary care physician.
And so if you need a referral,
um there there's some insurance plans that require you to
get a referral in order to go see a specialist.
Other plans do not.
And to make it even more confusing,
there are some plans where you don't necessarily need a referral,
but you need what's referred to as a pre authorization, right?
So,
so
yes,
literally is going through so many elements is the best thing to kind of start
with your insurance provider maybe before going
to the provider to ask these questions.
It depends on where you're coming from.
I mean, if there's a particular doctor or provider that you have really loved
and you are switching jobs, you're switching insurance plans
and you would really like to be able to keep that doctor,
then I would start by going to that provider and saying, hey,
which plans are in network and then let's say you're signing up
for a new insurance plan with um maybe you have a new job
as you're signing up for insurance plans.
You might have a menu of plans that you can choose from.
So you might be able to choose a plan that fits the provider that you already love.
So there there are different ways to do it.
You can either start with a provider and choose the plan that
they will accept or you can start with the insurance that you have
and then look through their menu of options to find me in network providers.
Oh, you're doing such a good job of breaking it down.
It is so complicated.
Um Any major changes coming from the government
that could impact our health care in 2024.
The biggest thing to know is that your premiums,
especially if you have private insurance are likely going
to go up and this is because of inflation,
right?
So uh there is on average about a 5% increase in premiums
for unsubsidized plans that are ac a affordable care act compliant.
Ok. So let's say your insurance has changed
knowing that on average, you mentioned prices are going to go up 5%.
But if you have new insurance, what can you expect from different medical bills?
The completely different.
So like we mentioned earlier, the deductible, the co pay the co insurance,
the annual out of pocket max,
all of these things are going very pretty wildly
as well as what we've talked about preauthorizations,
whether or not a referral is required.
All of that's gonna vary depending on what type of plan you have.
So you want to check your explanation of
benefits that EOB you wanna read through that
very carefully so that you understand all of the details of the plan that you're in
the simplest breakdown we could get Paula Pan. Thank you so much. Always a pleasure.
Thank you so much for having me