Non-Profit Internet Source for News, Events, History, & Culture of Northern Frederick & Carroll County Md./Southern Adams County Pa.


Understanding Health Insurance

(12/26) Health insurance is one of the most inscrutable aspects of American life. What should be relatively simple is instead anything but. Health insurance lingo is full of terms like "copay" and "pre-authorization" and "preferred provider." The Affordable Care Act, or Obamacare, is hobbled but still around, although you no longer have to have health insurance or risk facing a penalty on your taxes. It's a lot to absorb.

Networks and co-pays

Looking for a new doctor is a daunting experience. It's even more so when you think you've found the right office, only to be asked for your insurance information and told, "Sorry, but we're out of network," or, "Sorry, but we don't accept that insurance." It can get really maddening really fast. This is America; shouldn't decent insurance work just about anywhere in your city? Unfortunately, that's just not the way it works. American health insurance took a long time to become this complicated, and the odds aren't good that it's going to get fixed anytime soon. There's just not the political will to do that right now; Congress is preoccupied with other things. Basically, your insurance company can dictate where you need to go to get treatment. They'll have a list of providers that are "in network," which means that the providers accept your insurance, and also that the insurance will cover any claims from said provider. You, the patient, will usually have to pay a portion of the treatment costs out-of-pocket through what's known as a "co-pay." But first you have to meet a deductible, at least for certain treatments, and that deductible can range from a few hundred to a few thousand dollars annually.

What about things on your insurance company's end? Things are somewhat streamlined thanks to computers and things like insurance policy administration systems, but it's still not easy. Nothing about the healthcare system is easy, although insurance company executives are undoubtedly comforted by all the money they make in the process.  


In most cases, basic visits to a primary care physician are covered by insurance without you needing to do anything else. But if you want to see a specialist, you'll probably need a referral from another doctor, and you'll also need something called "pre-approval." That's where you basically have to call up your insurance company and say, "I'm seeking treatment for obsessive-compulsive disorder from a psychiatrist named Dr. Fitzgibbons. Is that OK?" If you don't get that approval, then your doctor's claim won't be approved, and then your doctor will have to bill you in full for the costs of your treatment. A $25 co-pay is bearable for most people, but without that insurance coverage, the cost of one visit to the doctor can be hundreds or even thousands of dollars.

The only thing worse than dealing with insurance companies, though, is not having any insurance company to deal with at all. Not having health insurance is one of the quickest paths to financial ruin in this country. Medical bankruptcies have decreased since the Affordable Care Act went into effect, but they're still too common. We've all seen the crowdfunding campaigns for uninsured people undergoing treatment for cancer or another terrible disease. If you're young and relatively healthy, you may be able to skate by without insurance, but it only takes one diagnosis for everything to change.