n. language that is meaningless or is made unintelligible by excessive use of abstruse technical terms; nonsense (dictionart.com)
I am blessed to have some really close friends on whom I can count for unconditional support. One is basically a copy of me, just with different anatomy. We even share a birthday. Although, maybe he is slightly rougher around the edges.
Last time I saw him, he told me he was going to have back surgery in March. This is progress – I usually don’t hear about these kinds of things until after the fact, which drives me nuts. But this time, he needed my help. He had no idea what was going to be covered by his insurance plan or how much it would ultimately cost. Seeing as it was open enrollment season, he wanted to make sure he chose a plan that would not leave him bankrupt on the other side of the surgery (and the longer recovery process).
Now, my friend is fairly intelligent, a lawyer who works for a government agency.
The conversation started with a few texts, but we realized quickly that it would be too complicated for just texting, so he emailed me the policy documents he had. Luckily, it was more than just the two page glossy brochure you usually get. It was actually some sort of comparative Summary Plan Description.
First, I suggested that he talk to his doctor to find out all of the components that would be involved in the surgery: providers, facility, rental of any special equipment, etc. Once he had that, he could call the insurance company to see what percentage of each piece would be covered.
But, as usual, it was more complicated than that. We ended up spending over an hour on the phone going over the policy and answering his questions. I kept thinking how ridiculous it was that anyone not specifically trained to read a health insurance policy was never going to be able to plan for costs or understand what their policy covers.
Even I am surprised by costs every once in a while, mostly having to do with how my psychologist is covered. It’s so frustrating, and the insurance companies depend on that frustration to keep you from getting what they owe you. It takes time, but you should know that first, second, and even third denials aren’t necessarily final.
After our discussion, I hope my friend feels better about going into his surgery. Maybe our discussion can help you, too. These were the things in his plan that he stumbled over:
Allowances: this is what the insurance company deems a reasonable cost for a service. Even if the service is in network, if it costs more than the insurance company allows, you have to pay whatever it says you owe of the allowed cost plus the portion above the allowance. An allowance is often called a ‘reasonable and customary’ cost.
In-network vs. Out-of-network: a surgery like my friend’s that has many different components may have a combination of in-and out-of-network costs. His doctor is out, but the facility is in. Each has a different deductible which must be met before the insurance company starts paying its full benefit. In some ways it would be less expensive to go all out-of-network because he would hit his deductible and out-of pocket maximum sooner. But that is almost never an option.
Out-of-pocket maxes: these were put in place in order to keep you from being bankrupted by high medical costs, like cancer treatment, which can be ridiculously expensive. But even an out-of-pocket max of $5,000 can feel catastrophic when you have student loan debt, or you are in a job where you are underpaid, or any number of circumstances. As it happens, there is a separate out-of-pocket max for in- and out-of-network costs, as there is for deductibles. In my friend’s case, he will have to meet both, but after that the insurance company should pay 100% of all covered costs.
Covered costs: every insurance policy has a list of procedures they will not cover. These are sometimes called ‘disallowed’.
Counting toward the deductible: not every cost will count toward meeting the deductible.
There are more pressing healthcare issues like prescription drug costs, access, and overuse, but if trying to decipher your policy has you laughing to keep from crying every time, just know that you are not alone. As the idea of more value-based, patient-centric care grows, so does the power of individual patient. (After all, it’s our needs and our money that funds this $3.5 trillion industry.)
Hopefully, once we are no longer at the mercy of our policies, the insurance companies will have to write their policies in a language other than gobbledygook.