Navigating Insurance Plans with an Eating Disorder

Dec 10, 2014

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Choosing a new insurance policy can be a daunting task. It requires knowledge of what treatment you may need to access in the upcoming year, a thorough look at your personal or family budget and hours of research into the Healthcare Marketplace.  We have had many individuals come to us enrolled in weak insurance plans with respect to the amount of care they require in a coverage year; we hope to change that for many people.

Disclaimer: Although this article is addressing HealthCare.gov options with respect to eating disorder treatment, much of the information can be applied to choosing an insurance plan through your employer.

A need for an insurance guide became apparent to us when we were working with an individual who recently emigrated to the U.S. from a country with socialized healthcare. At home, everything was paid for; if you needed to go to the doctor you would go with no fear of what it may cost. Moving to the U.S. she was overwhelmed by the cost of insurance as well as the cost of healthcare. The biggest tool that would’ve helped her was knowledge of what these crazy insurance terms actually mean (in English, not legal jargon), so we will start with some key insurance terms.

Key Insurance Terms

Premium – The dollar amount you will pay monthly to your insurance provider whether you are utilizing your insurance or not. If your premium is $150 a month, you will pay that monthly until your policy ends.

Deductible – The dollar amount you will pay directly for your healthcare costs. For most policies, until you have spent more than your deductible amount is, you will be 100% of your medical costs. For example, if you go to a doctor for what you think may be a broken ankle. The doctor may do an x-ray, provide an examination of the ankle and administer medicine and an ankle brace. If your deductible is $5000 and this visit cost you $2200, you will pay $2200. If your deductible is $500, you will pay $500 a percentage of the rest of the charges.

Out-of-Pocket Maximum – The maximum dollar amount you will pay for covered healthcare expenses in a year (outside of your premium). For example, you suffered a major injury in a skiing accident. You are rushed to the hospital; require intensive surgery and a night in the hospital which all costs $10,000. If your policy has an out-of-pocket maximum of $2500, even if you haven’t met your deductible, the most you will probably end up paying is $2500. Now, if your policy has an out-of-pocket max over $10,000 you will be paying for everything (including 100% for your deductible) plus the coinsurance outlined in your policy.

Coinsurance – Is a percentage you will pay for healthcare services typically after your deductible is met. For example, after you’ve met your $1000 deductible by paying 100% of your healthcare costs, you will now pay a % of your healthcare costs as outlined in your policy.

Copay – A fixed amount you will pay for healthcare services that will vary between in-network and out-of-network providers. For example, if you see your Doctor once a month and your copay is $20, you will only pay $20 for the visit. Sometimes copay and coinsurance are combined, you may pay $20 for the visit but pay a percent for services during the visit (such as a % of the cost of an MRI).

In-Network Provider – These providers have negotiated rates with your insurance policy. Visiting an in-network provider gives you access to these lower rates and saves you money.

Out-of-Network Provider – These providers typically have no reduced rates negotiated with your provider and you will pay full price for healthcare services.

Key Tips for Your Insurance Hunt

Now that you know the terms, the next big question is: how do I apply them to my search? Here are a few good tips for using these terms in your search:

  • Typically, a plan with a higher deductible (the amount you pay for healthcare services before insurance starts helping) will have a cheaper premium (the monthly amount you’ll pay no matter what). With a higher deductible you will be paying MUCH more upfront for accessing care. When recovering from an eating disorder, it is important to keep in mind that healthcare visits are often frequently made.
  • Compare your budget to your deductible and max-out-of pocket. If you were involved in a catastrophic event, hospitalized or required residential treatment, would you be able to cover the cost of your max-out-of pocket easily? With routine visits, are you able to pay 100% of your deductible?
  • If you travel a lot for work or pleasure check for in in-network and out-of-network providers in the areas you travel to most, this will provide peace of mind when you’re on the road and may need to make a visit to the doctor.
  • Is your current treatment team in-network for the new insurance policy you’re considering? If they aren’t, you may consider researching plans they are covered under.
  • Are you on special medications? What is the cost of those drugs on your plan? Do they count towards your deductible?

A big ticket for those with eating disorders is the Mental/Behavioral Health Outpatient & Inpatient services and charges. With the Affordable Care Act, you can’t be denied coverage or charged more because of your pre-existing mental or behavioral health condition. These benefits for mental and behavioral health are typically outlined under “Medical Management Programs” or “Other Benefits” on healthcare.gov plans.

With the below plan, you can see that mental/behavioral health visits are $25 for in-network. Check this on the plan you’re considering, is the cost listed something you can afford for the frequency you visit your treatment team? If it isn’t, consider looking at plans with a higher premium and better benefits for your needs. You may pay more per month but will save money by having more affordable access to care and, depending on the policy, free visits to your treatment team.

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Levels of Plans

When navigating HealthCare.gov you will search based on plan levels, here is a quick run-down of what to expect with respect to each of the categories:
Platinum – These plans typically cover 90% of healthcare costs and you will pay about 10%.
Gold – These plans typically cover 80% of healthcare costs and you will pay about 20%.
Silver – These plans typically cover 70% of healthcare costs and you will pay about 30%.
Bronze – These plans typically cover 60% of healthcare costs and you will pay about 40%.
Catastrophic – These plans typically pay less than 60% of healthcare costs and are not recommended to individuals who require ongoing healthcare treatment. They are also only available to individuals under the age of 30.

The Hunt Begins

Now that you’ve got the basics of navigating insurance policies down, head to HealthCare.gov and find the perfect plan for you. If you need any help choosing a policy feel free to call us at 435-938-6030, message us on Twitter or Facebook or email us at foundation@avalonhills.org.

Do you have any tips or recommendations for navigating insurance policies? Let us know by commenting!

P.S., Once you have a plan, call and ask for a copy of your benefits. Once you’ve received it, tuck them away with your important paperwork. If you ever need to file an insurance appeal or your insurance policy stops providing benefits this will be your saving grace. Look for an upcoming blog about getting the most out of your policy and communicating with insurance.
Happy Hunting!



Category: Health Care

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