Health Insurance — What Exactly Am I Buying?

Many of our clients complain about their inadequate health insurance coverage. Often, the cause is a lack of understanding regarding the true costs of coverage, as well as the inherent administrative barriers that exist.

Our goal, always, is to educate our clients. This way, they can make informed selections about Medicare coverage and/or purchases on the Open Market and avoid unwelcome surprises. Of course, when it comes to understanding the role of insurance, there are many factors to consider.

In our experience, these three things have the greatest impact…

Where you access care

When researching options, it is critical to identify the insurance networks in which your primary care physicians, specialists and preferred hospitals participate. Often, this is less straightforward than it may at first seem.

Consider the example of Joe, a recently retired 62-year-old man. Not yet 65, he was ineligible for Medicare. He wanted to purchase an insurance product that allowed him to seek care from a group of physicians associated with a hospital system that he had just retired from. He narrowed his choices to two Preferred Provider Organization (PPO) options. Although he was positive his doctors were in-network for both products, closer examination revealed a different story.

Many insurance products have “Select” networks; these are a subset of a larger provider network. As it turned out, for one of the company’s products, Joe’s doctors did not participate. He identified this only after some painstaking research — first, by looking at the provider network the insurance product listed online; next, by calling the business office of each physician; last, by calling the insurance company directly.

Because the difference between an in- and out-of-network benefit can be significant, verification of this kind can save you a lot of money. In Joe’s case, it meant the difference between 100% coverage with an in-network provider and just 50% out-of-network.

When you access care

At this time of year, we find ourselves reminding clients about deductibles — the set amount you must pay out-of-pocket at the beginning of a plan year, prior to your plan paying benefits. Deductibles are reset annually and can significantly impact your out-of-pocket cost until their requirements are met.

In the case of our client Joyce, and since she is enrolled in a Medicare Part D plan with a $435 yearly deductible that we calculated she would meet in March, we suggested she wait until then to obtain the Shingles vaccines. This way, her out-of-pocket copay for the vaccines will be significantly less than if she obtained them sooner.

How you access care

Joe’s insurance product required prior authorization for any in-patient surgical procedures. Joe knew this because he read the Evidence of Coverage document that accompanied his policy.

After speaking with his insurance company, Joe also learned that it was his surgeon’s responsibility to make the authorization request, so he assumed he was all set. (I think you can guess where this is going.)

Surprise. The day before the scheduled procedure, his doctor’s office called to cancel because there was no prior authorization. As it turned out, the surgeon’s office had not followed through as required.

In the end, and thanks to some last-minute assertive scrambling, the surgery occurred as planned. But it’s our premise that Joe should have confirmed well in advance, to make sure everyone had done their part.

Some Practical Suggestions

As you begin your new insurance plan year, be sure to do the following:

Read the fine print. The Evidence of Coverage outlines all the details. But we know, it’s a lot to read (often more than 100 pages). Another option is to call your insurance company, describe the scenario, and ask what needs to be done to ensure the most comprehensive care. Make sure to document the conversation in your notes and ask the customer service representative how they plan to do the same in their system.

Don’t make assumptions. Your physician is not in the insurance business. Don’t assume they know the specifics of your coverage or what the administrative requirements may be. Sometimes, a three-way call between you, your insurance company and a member of your provider’s business office is necessary. Ask the customer service representatives to outline the specific language in the Evidence of Coverage that addresses your issue. Again, document everything.

Verify and re-verify provider participation in a network. Network participation can change. Make sure your providers continue to be covered by your insurance products!


Few people enjoy learning about health insurance coverage and its impact on cost and treatment. But it is a reality with which we all must live.

Please, make it a practice to read information about your insurance in advance of receiving care and take advantage of the knowledgeable customer service representatives available to speak with you.

These actions can save you a lot of frustration, anxiety and cost, and allow you to focus on what really matters: taking the best care possible of yourself and your loved ones.