Eating Breakfast While Reading My New Health Insurance Benefits Booklet

My husband rolled his eyes when he saw me at the breakfast table thoroughly enjoying the reading of my new health insurance benefits booklet.  His comment was, “You are probably the only person who reads that from cover to cover.”  Yes, I do and I tell people it is important to read and know your benefits.  I also know, his employer doesn’t send out an email explaining changes.

My husband’s work changed carriers this year and we started in June.  The most common misconception by employees is the policy will provide the same benefits as before.  In this health care environment, you can be guaranteed to have some changes.  Everyone is trying to save as prices continue to rise.  The reason the carrier was changed was due to the old carrier wanted to raise rates by 12%.

Here is what I found when reading the booklet, the changes and what it means to me.  First, this is an HMO that requires you to only use designated centers for care.  This is slightly different than the “in network “concept.  In network is a much broader concept with the insurance company having contracts with multiple facilities and providers.  With this new insurance, I am much more limited as to my choice of hospitals and specialty centers.  The designated hospital is a smaller local hospital.  It means, I have to prove I can’t get care from a doctor or ER there.  As an HMO, they are expected to manage where I access care.  In Boston, there are five major centers but I my not have access to all of them as I want.

The other change is I know have higher copays and out of pocket maximum.  Luckily, I still have no coinsurance.

In reading the booklet, I was able to learn what services are and are not covered.  Under second opinion, it is covered if it is given by a provider in the network.  SO if I want to go to New York or Mayo Clinic, I have a fight on my hands.

What I was looking for was how people can get tripped up.  The devil is in the details as the saying goes.  It is that way with these benefits.  There are many possible ways to get denied if you don’t understand the benefits.  It is easy to think you are covered and find out later you weren’t.  You can’t count on your primary care to know the difference.

I can’t say it enough, know your benefits.  It helps to make an empowered patient.