Understanding insurance

[AnonymousDoctorGuyPerson]

Hey all, so, I'm only a M1 but mad people in my life come up to me with questions about insurance, different plans, HMOs, etc, etc. acting like I should know all of this (and honestly I probably should though),

I've been on Medicaid most of my adult life so my knowledge doesn't extend much beyond what I've personally dealt with. What is a decent, succinct, resource I could go through to have the knowledgebase to answer the ins and outs of insurance-based questions?

Thanks!

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[TragicalDrFaust]

Every insurance plan should have a summary of benefits or summary of coverage available along with a formulary for medications. All companies are different and most have different plans available. You would need to read this summary of benefits to understand everything. It is about as far from succinct as you can get. Plus, because every person's plan is different (you probably won't see two people with identical plans in a week), you have no hope at learning it all. For patients, it's good to have a general idea of what kind of medications, treatments and specialists are covered by most plans and roughly what they might cost (but no guarantees) and for people who have more complex questions, you may want to help them locate and understand the summary of benefits for their plan.

 

[longhaul3]

There's a book called The Healthcare Handbook that gives a reasonable high-level overview of insurance and other related topics.

 

[NickNaylor]

This is a difficult topic to become knowledgable about because there are so many different insurance plans, all with their own individual quirks. The basics are more or less the same, but the particulars - ”how much will this medication cost?,” “how much will I owe after being in the hospital?,” etc. - are impossible to predict. This is why many hospitals have full-time staff whose sole job is to deal with insurance-related issues.

Edit: after some quick Googling, this is actually a pretty nice overview of the basics: Health Insurance Basics | 101 Guide to Health Insurance for 2021

 

[Neopolymath]

It's purposely vague and indecipherable just like most lawyer-speak these days. It's a feature not a bug for them so don't sweat it. Read the basics and then you will continue to seek out and learn about the system as it pertains to your career.

 

[Opomfrog]

ya this is not something that comes intuitively to a lot of people

 

[ValeRx]

There are simply too many plans for you to even begin to learn. I spent nearly a decade in retail pharmacy and I got that question ALL the time. I'd simply tell each person that there are literally thousands of plans and it's in their best interests to do some research on each available plan. Or if they've got Medicare, to go to medicare.gov and there's a pretty cool compare tool they have in which they can add a list of their medications. Then the site will actually put a way for them to look at all of their potential copays.

 

[AnonymousDoctorGuyPerson]

Thanks folks! At least I feel less like an idiot now, helpless sure, but less of an idiot 😛

 

[Ho0v-man]

The only thing you should really know at this point is the stuff in FA on the matter.

 

[la flame]

I don't know much about insurance but for some reason, the doctor I shadowed went on a huge rant to me about how the insurance companies completely control doctors. Tbh I had no idea what he was talking about so I just nodded to what he said but it sounds like they hate physicians lol

 

[clinicallabguy]

Agree with above. You'll pick this up as you go along. If you're into podcasts, I'm sure there are several that will describe weird and interesting situations that demonstrate the quirks of the way insurance works and you're more likely to retain that than reading legalize. One that I have enjoyed in the past is An Arm and a Leg. Look it up if you're into podcasts. I shows some of the strange quirks and counter-intuitive ways that the financial part of the healthcare system is set up and how people have dealt with interesting financial problems they have found themselves in while getting healthcare.

 

[jambro]

As everyone else has mentioned there's probably thousands of plans that have their own rules so that's impossible to know.

but what you should know is:
a premium is what you pay for the privilege of having insurance. you pay this whether you use healthcare or not

your deductible is the part that you pay before your insurance will pay anything on your behalf. it resets once per year. so if your deductible is 5k/yr and you spend 4999 every year (on top of your premium) then you will go your whole life without your insurance company paying a single cent for your care

coinsurance is the % that you pay AFTER your deductible has been met. So you pay 100% of costs up until your deductible (say 5k) and then after that you might pay 30% of everything past that and the insurance company will finally kick in the other 70%. This also resets just like the deductible does after the year.

Your out of pocket max means once you've spent a certain amount per year (say 10k) you will not pay anything else and your insurance company will have to cover everything else. Resets at the end of the year

Being on medicaid you've been insulated from all of this. I contend that if you like the docs you have access to medicaid is the best insurance out there because you pay nothing ever