Frequently Asked Questions (and Answers) Regarding Healthcare Plans

I understand – all these plans and programs can be confusing! It’s hard enough just tracking changes to an existing plan from year to year; it’s even more difficult when you make a switch from one type of program to another.

This month, I share some of the questions I hear most frequently, and provide explanations and suggestions for getting the most out of your healthcare plan and that of your loved ones.

Questions that relate to all types of plans

I haven’t received my Plan Identification Card. What do I do if I need to access care or prescriptions?

Because of how busy open enrollment season is, insurance companies take some time to catch up. It is not unusual for your ID card to arrive after the January 1 effective date.

If you need to access care before you receive your card, you can do the following:

  • Call the insurance company to verify your enrollment and to obtain your ID number over the phone. You can then give it to your provider or pharmacy. (Some providers and pharmacies can even find your ID number directly through their electronic systems.)
  • Once you do get your card, be sure to show it to all the providers and pharmacies you work with. This will help to ensure accuracy of billing.

I didn’t pay much attention to open enrollment season. In January, when I went to the doctor, I was charged a different co-payment amount and my prescriptions seem to cost more this year. What happened?

Many of us take the path of least resistance, letting our plans roll over to the next year, assuming all will remain the same. Unfortunately, this is often not the case. The plan may have changed, leading to these kinds of “surprises.”

The good news is it is never too late to learn about the plan you’re in. Here are some suggestions for doing exactly that:

  • Some insurance companies have online member portals in which you can enroll, allowing you to easily access information about your plan.
  • The back of your ID card will have a customer service number that you can call. Here’s an example of what to say:”I’m seeing a hand specialist this week named Dr. John Smith from New England Baptist Hospital. Can you tell me what my coverage level is for this visit and what I can expect to pay out-of-pocket?”

What does it mean for my deductibles to “reset” at the beginning of the year?

Almost all plans have a deductible – the amount you must pay out-of-pocket before the plan begins to pay, according to the outlined benefits. Deductibles are reset as of January 1, so a service or medication you paid $X for in December can be much more expensive now. It will remain that way until you again reach your deductible in the new year. If you’re not sure how this is playing out for you, here is an example of questions to ask your plan’s customer service department:

“What is my deductible for health care services and for medications? Are they different amounts or do they get combined? How does this impact what I am expected to pay out-of-pocket to access health care services or prescription drugs? How can I monitor my progress toward meeting my deductible?

Questions specific to Medicare Part D Prescription Drug Plans

I made my decision about the most cost-effective plan based on my panel of medications in December. But I just had my yearly physical during which dosages were changed and new medications were added. What happens now?

Unfortunately, you have to work within the plan you have for 2018, as you cannot make a change until next Open Enrollment season (the new plan would be effective January 1, 2019).

Here are some ideas for managing in the meantime:

  • Contact the insurance plan to identify if the new medications being prescribed are on formulary (covered) by the plan.
  • If they are not, ask what other replacement drugs could be prescribed that are covered; discuss the recommendations with your physician. Because physicians are not familiar with the coverage levels and cost sharing requirements of the numerous plans their patients are enrolled in, these conversations can sometimes result in an alternative medication being prescribed that is just as effective and much less expensive for you.
  • Identify what tier the drug falls into so that you can match it up to the co-pay or co-insurance amount for which you will be responsible.
  • Ask what the full cost of the drug is so that you can anticipate if the change will result in you entering the donut hole. If so, find out what will then happen to your monthly prescription drug cost.
  • If you know how to use the algorithm on the website, you can re-run your analysis with your new panel of medications to see how it compares to the analysis done in December.

Questions specific to new Medicare enrollment

How do I know if I’m responsible for an Income-Related Monthly Adjustment Amount (IRMAA) in addition to my Medicare Part B and Part D premiums?

Once you enroll in Medicare, you will receive numerous letters from Centers for Medicare and Medicaid Services about the cost for Part B and any associated IRMAAs. What’s frustrating for consumers is that you receive multiple letters, the contents of which can be a bit confusing. Also, once you start to receive bills, a catch up is going on and you can’t clearly tell what you’re paying for – the premium, the IRMAA, which IRMAA, or some combination of the above.

Most of the time, the amounts are correct but we often find it takes a few months for all the catch up to happen and for regular monthly amounts to become the same. Here are some suggestions:

  • When you first enroll, request to be billed monthly to be sure all is correct before you enroll in any electronic payment format. In the event mistakes happen, it makes it easier to adjust.
  • Once you know if an IRMAA is assessed on Part B and Part D, and you know what your Part B premium is, track your monthly bill amount for several months to monitor for accuracy.


Unless you happen to work in the insurance industry, you may not be familiar with all of its idiosyncrasies, let alone the “insurance speak” of health insurance. But don’t worry – you don’t need to be an expert to improve your insurance literacy. Provided you remain inquisitive and are willing to invest just a little bit of time in the process, you’ll soon get a handle on the essentials.

Remember as well that if you receive an explanation from a customer service representative and still don’t feel satisfied, just pick up the phone and call again. Another person may do a better job of explaining things with words you can understand. If all else fails, don’t be shy – ask to speak with a supervisor.

In the long run, time invested early in your plan year almost always leads to greater satisfaction!