Even experts have trouble figuring out how certain aspects of health insurance policies work, and that leaves most people having only a vague idea of what their health insurance entitles them to receive. All too often, some major misunderstandings about the ins and outs of health insurance coverage lead to costly mistakes. Below, we'll look at three particularly common pitfalls that people fall into in coordinating their healthcare needs with their insurance.
Misunderstanding 1: Believing that premiums are the only important thing about health insurance policies.
The goal of health insurance is to pick a policy that minimizes your total healthcare costs. However, many people fall into the trap of focusing solely on the monthly premium that a health insurance policy charges. Because the monthly premium is often the only certain cost figure you know about, it's understandable that people drill down on trying to save on premiums. However, in some cases, the policies that have the lowest premiums don't provide the coverage you need.
For example, shortly after Medicare Part D prescription drug coverage became available, researchers looked at the choices that people made. The study found that only about one in three picked the Part D plan that minimized their total costs, with too many choosing policies that involved smaller premiums but more out-of-pocket costs. Looking closely at what a policy covers and what your particular healthcare needs are is crucial to make sure you choose the policy that's best for your situation.
Misunderstanding 2: Not knowing whether a particular service is covered.
Nearly all health insurance policies provide coverage for basic needs like doctor visits and hospital stays, and so there's little misunderstanding about those services. However, in many cases, people aren't aware that their policies cover certain less common needs, while others mistakenly believe that policies cover things that they don't in fact cover.
One common example of a commonly misunderstood area is mental health, where coverage across policies has historically differed greatly. The Affordable Care Act provided a substantial expansion of mental health coverage, requiring most individual and small-employer health insurance plans to cover services related to mental health and substance abuse disorders. On the other hand, many services routinely don't get covered by traditional health insurance, such as dental care and long-term care for those in need of nursing homes, assisted living arrangements, or home healthcare.
Misunderstanding 3: Failing to follow procedures for certain situations.
The most common example involves the concept of the primary care physician, who most people understand is responsible for acting as the gatekeeper for related medical services on your behalf. Rather than simply going directly to a specialist, you usually have to get a referral from your primary care physician. If you fail to do so, then you run the risk of not having the charges covered.
Other situations can also lead to similar difficulties down the road. For example, if you need emergency care when you're traveling or otherwise outside your regular network area, then most policies will cover visits to emergency rooms. Insurers aren't allowed to require prior approval before covering emergency room services even if you're outside your network, but they can set reasonable guidelines for notification after emergency care. For instance, one health insurance company suggests that you immediately notify your primary care doctor and the insurer if you are admitted to a hospital or other inpatient facility. In other emergency cases, the company requests notification within 48 hours. Failing to follow such procedures doesn't always lead to having coverage denied, but it can cause complications that are best avoided if possible.
Health insurance can be hard to understand, and it's easy to make mistakes about your coverage. By being aware that your initial impression of your health insurance might be wrong, you'll be on your guard to ensure that when you truly need your insurance coverage, you'll get the most money possible to cover your healthcare costs.