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Health insurance is one of the most complicated things that many of us have to deal with.  What's covered?  What isn't covered?  What's in network? Out of network?  How much are my deductibles?  Do I have to call someone to get this or get something to see that doctor?  Put twenty people in a room together and ask them to talk about their insurance and chances are you'll have twenty varying answers.

The temptation is to simply throw up ones hands and just give up trying to understand, and then hope for the best in the time between when you present your insurance card and when you get that bill from the provider.

I'm telling you, that's a bad strategy.

Sick On A Trip

Earlier this summer, on one of our camping trips, my son became ill.  He developed a fever, a rash, was tired, and had a loss of appetite.  We controlled the fever, checked for ticks (we were camping), and waited a couple of days to see if things would pass.  They didn't, so we knew that we had to find medical attention for him.

Since we were four hours away from home, coupled with the fact that it was a holiday weekend, we knew that our options were limited.  We were near a very small town with one doctor's office, and that was pretty much it in terms of options.

Having read through my basic health plan information a few times during and after signing up, I knew that if we were going out of network, I was expected to contact the provider beforehand (if possible) and let them know.

I called and, since it was a holiday weekend, I had to leave a message. I let them know my son's name, member ID, my name, my ID, and the facility and phone number we were taking him to.

We took him for care, and after being diagnosed with a virus, he started showing improvement within a couple of days.

I waited a few weeks and saw the claim information pop up.

Fully Denied.


The bill would have been about $130.

But, because I understood our plan, I had a feeling that this wasn't right.  I called and spoke to someone in member services.  She took down some basic information, noted our location at the time, noted that I had called, but then saw that the claim had been entered as a standard ‘office visit', where given the circumstances it needed to be classified as an urgent visit.

She resubmitted this and within 10 days, the claim was adjusted, and our cost was $40.

Which is exactly what I expected.

Had I not taken the time to understand a few of the basics, I would have probably missed the step where I was supposed to call and notify them of an out-of-network visit.  I also might have simply accepted that it was out of network and paid the full $130.

By understanding the basics, I was able to close a potential loophole that could have denied service, as well as argue my case for coverage.

While you can't be expected to know every detail, there are things you should be able to answer about your plan.  For some reason, I picture Keanu Reaves in Speed asking “OK, hotshot, (read any question below).  What do you do?    What do you do?”

  1. What is your preventative coverage?  You should know if routine checkups, immunizations, and other visits are covered.
  2. Is preventative care required? Some insurance companies not only cover your preventative care, but they'll entice you to take advantage of the checkups by form of lower deductibles or co-pays.
  3. What type of coverage do you have?  Do you have a PPO?  An HMO?  Another type of insurance?  You should know this as well as the basic implications tied to the type of plan.
  4. Are you tied to a provider?  We have an HMO so our coverage is tied to providers associated with a particular health care system.  This could be the case for many types.  If you know this, then any time you call a provider office, you can ask if they're associated with your provider.
  5. What are your co-pays? Many insurance cards have this printed on the card.  If not, you should get a list of common co-pays associated with doctor visits, specialist visits, urgent care, emergency visits, and other visits.
  6. What is your deductible? If you have to pay a certain amount of your health care before insurance kicks in, you should know this amount, and also have a good idea where you stand.
  7. Where are you covered? Going back to earlier points, if you are associated with a provider, you should know where the limits of that coverage extend.
  8. What happens if you go outside of your provider network?  I associate this with ‘roaming'.  You can certainly get care elsewhere, just as you can get cell phone coverage outside of your network, but what will your insurance company do if you choose to do so?  Many times (as was the case with our claim), they will accept the claim if you can prove that you could not get care from the preferred providers in a reasonable fashion (we were 4+ hours away).

These are eight things that I came up with, off the top of my head, that will greatly benefit you and that I don't think are too hard to learn, and that Keanu Reaves would be happy if you could answer.

Most insurance plans have a summary document, usually only a few pages long.  You'll often have access to this when signing up, and I would say that it's important to read that a couple of times.  It's not the most exciting reading in the world, but it's important.  It can save you time, money, and a whole lot of stress.

Readers, what level of knowledge do you have with your insurance plan?