This article about deadly superbugs is frightening. It’s one of the many reasons we work so hard to prevent our clients from being hospitalized.
Within just a few days of each other, the following things happened…
First, and as discussed in a previous newsletter, my dad was successful in resubmitting an improperly coded surgery bill. Once his claim was reviewed, he paid just $300 instead of the $6,500 bill he had rightfully questioned. I’m so grateful he brought it to my attention.
Second, I resolved my own $1,200 claim for a bill I received from an anesthesiologist following wrist surgery last summer. The entire amount was covered by the insurance company despite numerous claims that it was not.
Third, I read a moving article about a woman who did everything right to prepare for her son’s surgery, only to be faced with a $12,000 bill that caused her incredible anxiety.
Lastly, I was interviewed by representatives of CIBC Private Wealth Management for their Podcast targeted to younger clients, a program that strives to improve their audience’s financial literacy. Because health care costs must be considered as part of any financial planning, they asked me to elaborate on the advice I would give to young adults on the topic.
Taken together, all of these things got me thinking about the importance of teaching “insurance literacy” early to our young adult friends and loved ones.
What follows are my recommendations, broken out by phase of life!
At the Age of Twenty-Six…
In my experience, young adults insured on their parents’ health insurance plans rarely pay much attention to their coverage levels. They rely heavily on their parents to manage both their healthcare and their insurance. As a result of The Affordable Care Act, that arrangement can continue until the age of 26.
After that, and whether because they now have to purchase health insurance on the open market or because they have the good fortune of being employed and able to avail themselves of an employer-sponsored plan, they begin to take interest and the questions arise:
- I’m young, why do I need insurance?
- I’m healthy, why should I spend the money?
- What if I don’t have the money?
At this point, I focus on the idea of mitigating risk against a huge unanticipated healthcare cost. We talk about the potential costs associated with an unexpected illness, accident and/or the necessity of a costly hospitalization.
We also talk about the concept of an out-of-pocket (OOP) maximum — the maximum amount an individual would pay for healthcare services, beyond the cost of monthly premium, after which a plan pays healthcare expenses at 100%.
For example, a plan may have an OOP Max of $7,500. If an accident results in $100,000 worth of bills, the most you would have to pay is $7,500. This coverage not only protects the young adult, it also offers comfort and relief to anxious parents.
In terms of the cost itself, it’s worth exploring plans available through a state healthcare exchange in which income data is considered to identify eligibility for financial assistance, to defray the cost of the premium and OOP expenses. Depending on income, excellent options may be available at minimal cost. What a relief for everyone involved!
Getting that First “Real” Job…
Having a portion of the premium subsidized by an employer can be a fabulous benefit and one that should not be ignored. At this stage, I recommend understanding and paying attention to the following:
- Employee contribution. The monthly amount an individual pays toward the premium.
- Employer contribution. It’s good to know how much the employer is contributing. It gives an employee a true sense of the value of the benefit and should be considered, especially if a job change may happen.
- Deductible. This refers to the initial amount the employee must pay for health care-related expenses — out-of-pocket and in addition to any premiums — before the plan begins to pay any benefits. Many young individuals, especially if healthy, are surprised to learn that they must budget additional money for this. And while many never meet the deductible thanks to their youth and good health, one sports-related injury can change all that!
Starting a Family…
When individuals marry and/or begin to have children, health insurance concerns once again take center stage. The decision to keep individual plans vs. having both members of the couple on one plan should be made following a thorough analysis. It should begin by assessing the health status of those involved, concentrating on the specific benefit coverage levels of services likely to be used and their anticipated costs.
Adding a child to the mix creates an interest in maternity and hospitalization benefits, as well as the coverage details for the baby once he/she arrives.
At All Stages of Life…
Overall (and at any age), when making decisions about health insurance there are two important considerations:
What’s the status of my health and/or anyone else that might be covered on my plan?
This gets to how much or little you will expect to use your insurance and, if needed, what benefits you are likely to use.
For example, if you have an old sports injury that is now limiting your normal workout routine, you may want to investigate coverage for surgery and rehab with significant physical therapy. Focusing on outpatient surgical benefits, coverage for the physician and anesthesiologist, and co-pays for physical therapy, will help manage expectations.
What are the requirements for using my insurance to ensure I receive the maximum benefit?
When you enroll in a plan you are agreeing to a set of “contractual rules” — rules which you must follow in order to receive coverage.
For example, you may need a referral before accessing specialist care. You may need to ensure that your physician, hospital and any specialist care such as anesthesiology are considered in-network. Or you may need to gain prior-authorization for care. Each of these and more can have a significant impact on your coverage, so make sure you are clear regarding what your policy requires.
I am certain the topic of health insurance is not as exciting to young adults as it is to me! But, it remains one of life’s necessary evils.
In the United States, in particular, it is incumbent upon each of us to manage the health insurance market available to us and to become an educated healthcare consumer.
Make informed choices and limit any surprises. The earlier in life you begin, the more smoothly things will go in the future!
Many of our clients are forced to deal with both a major illness as well as the administrative burden of managing their insurance. This article highlights that unfortunate reality.
As professionals who guide Medicare recipients through administrative barriers experienced when accessing care, we found this article very disturbing.
This was a moving piece about the impact of depression and the importance of friendship.
Studies regarding job satisfaction have demonstrated that beyond basic financial security, it is things like autonomy, working with people you respect and feeling that your labors are meaningful/making the world better, that contribute to happiness at work: “A job is usually more than just a means to a paycheck. It’s a source of purpose and meaning, a place in the world.”
In my case, there were many times while working in varied corporate roles when I wondered if what I had done all day had any real value. Today, by contrast, I am happy to say that I feel extremely fortunate — I LOVE what I do at Healthassist!
Sharing my insider knowledge of how the healthcare system works with clients — many of whom feel frustrated and overwhelmed — and helping them to achieve a sense of mastery and control, is incredibly gratifying and keeps me working very hard on their behalf every day.
Recently, after receiving many requests (often in social situations) for some “on the spot advice” about a healthcare or insurance situation, I decided to make this a standard offering: Clients simply register online for a one-hour, as needed phone consultation at their convenience.
I’ve done many of these now and have found that certain topics come up again and again, including:
If you have a primary care physician or specialist with whom you don’t feel completely satisfied, rest assured that you are not alone. I hear this one frequently!
Clients report that while they may have regard for the physician and his/her competence, they describe interactions they perceive to be one-sided; they just don’t feel listened to and/or heard.
In these circumstances, my advice is to always assume the physician is also motivated to have a mutually satisfying interaction. The first action, therefore, is to address the topic of “our relationship / communication,” and to include it on your agenda for the next scheduled meeting.
Here is what you can say when you sit down together:
“Our mutual relationship is of great value to me and I’d like to expend some effort on enhancing it. I’d like to discuss how we communicate and what works best for both of us.”
From there, you can discuss past interactions (how they left you feeling and how you would have preferred them) as well as what you would like to see going forward (e.g., sharing your agenda at the beginning of a meeting, sending an email in advance, your preferences regarding phone conversations).
Most physicians tell me they are grateful when a patient brings up this topic, especially when a patient feels unsettled. They recognize that methods of communication need to be customized to each patient and are eager for the opportunity to improve.
Medicare: When to enroll? How to enroll? What to choose? Help!
There are many options regarding when, how and at what level to enroll. These variations are necessarily specific to each individual and my work with clients focuses on sorting all of this out and creating a customized game plan.
One area that people find particularly confusing is the difference between Original Medicare and a Medicare Advantage Plan.
Original Medicare, including Part A and Part B, pays for approximately 80% of health care costs. If you add a Medigap/supplemental plan, it can cover all your healthcare costs and result in little out-of-pocket expenses. I call this a “pay up-front” plan and it generally costs more than the option below.
A Medicare Advantage Plan, on the other hand, functions like an HMO or PPO plan obtained through employers. It may or may not have an additional premium and deductible associated with it and always has additional out-of-pocket expenses for co-pays and co-insurance amounts. I call this a “pay as you go” plan, and while it may appear to be less expensive, the devil is in the details of how, where and when you access care.
A careful analysis of an individual situation, taking into account preferences for coverage, other family members that must have health insurance, where you live and your income from the two years prior to reverting to Medicare, all must be considered.
Working with my Insurance Company
Questions in this area tend to focus on understanding the various components of insurance and coverage, as well as how to file claims for things like long-term-care insurance policies.
One topic that nearly always arises has to do with the difference between an HMO (Health Maintenance Organization) and a PPO (Preferred Provider Organization).
An HMO is the more restrictive of the two. You must identify a primary-care physician, you must obtain referrals from her/him to see specialists and you must stay within a network of doctors and hospitals.
A PPO has fewer restrictions. It does not always require you to have a primary care physician or to obtain referrals. Also, financial coverage is greater if you stay within the network of doctors and hospitals. If you go outside the network, you still have some financial coverage.
I have the incredible privilege of waking up every day knowing that I love what I’m going to be doing. Having a fabulous team of highly skilled professionals to work with contributes to that feeling.
But mostly, it’s the clients I love — the ability to enter their lives at what often are very vulnerable times, to develop a relationship with them, and to share some of my insider knowledge in the hope of making their lives just a little bit easier. To me, that is simply the best!
I appreciated this recent commentary regarding paid leave and the caring of the older adults in our lives. Click here to read.
I remain committed to Simmons University for so many reasons, one of which is the university’s research on gender in organizations.
For example, at the last four women’s leadership conferences I attended, “men allyship” was a subject of discussion. This important topic has gained much visibility, both as a role that individual men take up, as well as an organizational strategy for enhancing gender equity. Take a look at some recent findings, here.