Let’s assume that the recent news events lead to little or no reform in healthcare and the companies like UnitedHealthCare, Aetna, BCBS, Cigna, Kaiser, etc. plug on with their usual practices as before.
The best defense is a proactive one, to to keep oneself in the best of health so that you’ll never be at the mercy of the healthcare system - no smoking, no drinking, eat healthy, stay thin, etc. But everyone ages, and accidents are unavoidable.
Aside from purchasing a gold-plated insurance plan that is so gilded that even the insurance sharks themselves can’t legally deny you treatment when the day comes that you need it (a luxurious plan that most Americans couldn’t afford,) what other measures can we customers take to prevent Brian Thompson/Andrew Witty Syndrome where the company will try as hard as it can to make us one of the 32% denied stats? Are there special tactics or plans or provisions we should purchase to avoid getting screwed over on emergency-room day?
Aside from not getting sick, here are the following you should do to understand your benefits.
Read the schedule of benefits (SOB). This schedule includes services covered by your plan and how much you can expect to spend. i.e. Co-payments, co-insurance, your deductible, and maximum out-of-pocket expenses.
Read the Summary Plan Description (SPD). The SPD explains the rights and responsibilities of the insurance company as well as the covered individual. You’ll find information there on how to appeal a denial.
Make sure you’re receiving in-network care. Federal law mandates emergency care is always in-network, but otherwise you need to check and make sure.
Pay attention to how the plan works when HR goes over it at new hire orientation or during an open enrollment presentation.
PAY ATTENTION during new hire orientation and open enrollment.
I’m a benefits administrator in human resources, and a good chunk of the questions I answer are from employees who don’t understand their benefits. It’s complicated, yes, but a lot of times they don’t know about their benefits because they didn’t take the time to learn anything about them.
Don’t forget about preventative medicine, like annual check-ups or screenings if you have had an issue in the past. These can detect a small, resolvable problem before it becomes something else. Insurance should cover routine exams and doctor visits for shots, etc - and if it does not, you need to get a better plan.
One thing you can always do when the doctor says you need something - ask them how much it’s going to cost you. As mentioned in other threads, pricing is opaque - okay fair enough - then tell me what my cost will be up front, then I can decide if I want to do it or get another opinion, or ask about alternatives. Or just tell the doctor you cannot afford it. Ask for cost before you have something done - same for prescription medications. Make them pre-auth it with insurance and get the estimate in writing so all costs to you are known - don’t wait for the bill and be surprised - get out-the-door pricing like you would for buying a car.
If something is not covered by insurance, call them and ask why. Ask the doctor why it’s not covered. You need to be your own advocate - sometimes there are exceptions and less costly alternatives and if you push a little you might be surprised.
I’ve found seeing my doctor twice every year so worthwhile so she can hold me to what I’m doing. I’m not sure to what extent doctors can influence a claim’s success but she’s shared with me how she’s advocated for me with her superintendent. I believe she’s got swing.
Frugalize your lifestyle and build up your assets. This way you can pay for stuff your insurance won’t cover (as well as copays & deductibles) and for living expenses for when you can’t work.
How old are you? Not sure I can see my doctor twice a year and have it covered. Right now, to get a preventative checkup is about 4 months out (I know because I scheduled one and was surprised at how long the wait is).
Ask the insurance company, not the doctor, whether something is covered by your plan. Doctors don’t know the nuances of your plan and how it works. They may say that they take your insurance, but that doesn’t mean that some particular procedure, diagnosis or treatment is covered,
This doesn’t work in my experience. In the past I had been between insurance coverage and tried to find the best price for an MRI. Not one of the hospitals I called could tell me a price.
Maybe it’s better now but that was a real slog.
Recently I have been trying to find out about Medicare coverage for a particular infusion therapy I need to have annually for five years. No one in the hematology clinic seemed to be able to help.
I am a social worker with 30 years experience dealing with navigating systems. It’s mind numbingly depressing at times.
I’m 48 yrs old and have a medium-level deductible plan thru my employer. I have a condition that my plan treats within network. I do some online appointments 2x/yr that are naturally cheaper than going in. And the relationship’s perhaps unusual because my doctor is actually my best friend’s sister from childhood.
Look up statistics on the companies and choose the one with the lowest profit percentage and the highest payout rate per patient.
If, instead, you just look for cheap insurance then you’re basically looking for the company that does the opposite of what you want. It doesn’t become cheap through outsourcing to China. That’s not how insurance works.
I recently signed up for a health insurance using the marketplace exchange at healthcare dot gov. Last years policy was available with “new convenience pricing”. Reading the SOB I learned it was a bit lower deductible, that was good news. Reading further I learned that the coverages after the deductible would be partly my responsibility in copays. Unlike last years where everything was 100%covered after I reached my deductible.
Another look and I found the same insurance provider, same premium but with a bit higher deductible was another policy that had a new policy number but was exactly same coverages as I have now. I chose that one as I think it’ll serve me better in case of an unexpected emergency or hospitalization.
Still the premium is a fucking lot, I liken it to an exorbitant cover charge just to access negotiable pricing. Paid in spades for decades to hve health insurance that went largely unutilized. Because I’m healthy! (Knock wood)
It’s a year later and tomorrow I have an appointment to sign up for health insurance (so called) on the exchange, since I don’t currently have a job.
End of next year I will be able to get on Medicare (if it hasn’t been dismantled yet) so I will be deciding on a plan for the first 9 months of the year.
Probably won’t go this route but am honestly considering going without, since it will cost so much and - near as I can tell - not cover much. As an example, this past year I had to have an iron infusion and insurance paid a couple hundred dollars and I was billed over $3K.
I realize it’s a gamble. I probably won’t take it. BUT the whole subject is so complicated and fraught it might almost be worth it not to have to deal with an insurance company.
I’m not sure I want to every drop the insurance I had through work. I have the option to keep it, and right now it’s about 750 a month. I’ll be tempted to keep it instead of going the medicare/medigap route since I know what I’m getting.
I just last week had an appointment for a breast ultrasound. When I arrive, I’m told that some insurance companies no longer cover screening ultrasounds but they couldn’t tell me how much it would cost me if my insurance didn’t pay. The staff member told me the insurance company decides how much I will pay if they don’t cover it. After speaking to someone else, I think the idea is that once they bill the insurance the contracted price, that’s the price even if the insurance doesn’t cover it and I pay myself. Which might be great for me - or maybe not. I didn’t even care if I got the actual price- I was just looking for the maximum price. Because right now, I have no idea if I will be paying $200 or $2000 if my insurance doesn’t cover it. But I couldn’t get any price at all out of them.
And they kept going on about wanting to be “transaparent”…
What you’ll want to make sure that you understand, if you make that choice, is what the negotiated rates for procedures and visits you’re likely to make in 2026 cost via the insurer you’re looking at, versus the “rack” (non-negotiated) rates are for those procedures at your healthcare provider.
For example, the “cost” of that iron infusion you had was ~$3,500, of which you had to pay $3,000 out-of-pocket, but that “cost” was very likely the price that your insurance company has negotiated with your provider. You’ll want to understand what the non-negotiated cost would have been (especially if you’re likely to need it again); odds are it’ll be substantially higher than $3,500, and you would, of course, have to pay it all out-of-pocket.
Even with a high deductible, it’s not entirely true that individual health insurance does “not cover much” – the issue is that, until you meet your deductible, it may feel that way. If it’s an ACA / exchange plan, by law, it must cover a wide range of “essential benefits,” including preventive care. But, even it feels like your insurance isn’t “covering much,” you’re likely benefiting from those negotiated rates, and the fact that you have insurance will make many providers more likely to be willing to even deal with you.
Very unlikely to go without, was just wishing I could. In the past I have, but that was with a concierge doctor that I trusted and no assets to protect.
I get it. I’ve been a freelancer for the past year-plus, and have to buy my own coverage.
My wife and I are both too young for Medicare (I’ll be 61 in March, she’ll be 63 in January), and the rates for ACA plans for 2026 are truly eye-watering. But, I have several chronic conditions which entail regular checks with my specialists, as well as the reality that we’re in our 60s, and significant health issues could develop at any time…so going without insurance isn’t really an option. We can afford it (and I recognize that many simply can’t), but it’s still a helluva lot of money.
ETA: didn’t realize the post I’m replying to is a year old…
I just went through this in June. I was able to get prices from the hospital and 3 different outpatient MRI labs. It was a big hassle, and it took extra weeks of then getting the doctor referral, MRI lab, and insurance company approval to coordinate. It ended up adding about 3 weeks extra getting things lined up, and a lot of time on the phone when I was at work. It saved a few hundred dollars.
Seven years ago when I needed an MRI, the insurance company contacted me to tell me that if I changed my appt from the hospital to the freestanding lab up the street, it would cost a $4,000 less(!). I’m with a different insurance company now which is not so pro-active.
