When you get a new health insurance plan, it complicates things.
Sometimes you might choose to make this switch, but other times it may be that your employer switches insurance carriers or changes the plan options.
Either way, there are some clear steps you can take to avoid getting overcharged or ending up with a big bill under a new health insurance plan or provider. Athos Health's Jonathon Hess, our Health Care Hacker, lays them out for us.
1. Ask for the Summary Plan Description (SPD) document.
Warning: It's long and boring. But it lays out what the plan covers, and what it doesn't. Usually that part is in somewhere in the middle section.
Common issues that you should watch for in the SPD:
- Consider the plan's limit on therapies. Some plans limit how many therapies you can have per year (e.g. 20 chiropractor visits per year).
- Check coverage for a specific service or procedure you're interested in, such as LASIK, infertility treatment or bariatric surgery. Look at whether it's covered, and what level it's covered at.
2. Make sure your doctor's in network.
Unfortunately, not everything is in the SPD. It won't tell you if your specific doctor, clinic or hospital is in network.
So you need to go to the insurance company's website and search for your doctor to see if they're covered under your plan.
Do not assume that if you have the same health insurance company but a different plan, your doctor will still be in network. A health insurance company can have different networks depending on the plan.
3. Make sure your prescription drugs are covered.
The next thing you need to look for is the formulary.
This is not in the SPD, either. It lists which prescriptions are covered under your new plan. You'll want to make sure the drugs you take are listed as covered in that formulary.
What do you do if your doctor is out of network, or some care you need or drug you take is not covered?
- First off, if it's an issue of continuation of care - say you just had surgery, or you're pregnant, or you are battling cancer - you can usually continue to see the same doctor for a period of time. It's laid out in your SPD, but oftentimes for 90 days you can see that doctor and they'll be treated as if they're in network. Please review your plan before you make a decision about this.
- You can also appeal coverage. So if there's a drug that you take for a specific medical reason, your doctor can put in a medical necessity appeal and try to get the drug added to your formulary.
- Another possibility if your drug is not listed in the formulary: Ask your doctor if there's a similar drug that you can take that is covered by your new plan.
- If your doctor is out of network and you still want to see them, talk to them. They may be willing to negotiate a lower rate so that you can continue to be their patient.
In summary, don't get overwhelmed by a new insurance carrier or a new plan. Start by researching three main things:
- Is your doctor in network?
- Is your drug still in network?
- If you need services regularly, check the SPD to make sure they're covered.