This year, I will cover topics and provide resources to help YOU be your best advocate as a patient in the complex, costly, and sometimes dangerous system. In this article, I talk about how to make the most of your health insurance policy.

Why is it important to be your own best advocate when entering the healthcare system? The healthcare system is complex and runs differently than any other system we use as consumers. Navigating the healthcare system alone when sick or frightened is not a good idea. Asking a family member or a trusted friend to accompany you when you go to the hospital, a doctor’s appointment, or a therapy appointment is a good idea. As they say, two eyes and ears are better than one!

Most people can navigate the healthcare system reasonably well. As the Pareto Principle points out, 80 percent of the population will do well, but 20 percent will need help. We are never sure when we will fall into that 20 percent, so learning how to use the healthcare system and understand how it works is vital for everyone.

I will start with health insurance and explain how it works and how you can make it work best for you and your family members.

Let’s get started:

Health Insurance – In simple terms, health insurance is an agreement between you and a health insurance company. When you enroll in a health plan, the insurance company agrees to pay for certain health care services, like preventive care and other covered medical services. Having health insurance helps you pay for services to manage your health care.

But finding health insurance to meet your individual needs is challenging. Most of us receive health insurance as a benefit from our employer. Health Insurance is an important benefit, but an employer’s health plan can limit your choices. Most employers offer one policy for all. Many employers use a broker to help them choose a policy for their employees. Brokers try to limit the employer’s costs, so the policies they may select may not be best for the employee. Healthcare Insurance costs have risen over the years, so many employers can no longer afford to offer health insurance for their employees, and those who do pass more and more costs onto the consumer.

Many employers offer Health Maintenance Organizations Insurance (HMOs) with restrive policies to contain costs. A PPO policy offers more choices but is also more expensive. An HMO policy requires you to go to a primary care provider for approval of any services. To use the policy appropriately, you must stay within a specific network. Follow the rules to ensure the insurance company will cover your services. The key to using your health insurance policy correctly is to choose a family doctor or primary care physician who will work with you to manage your health. They will guide you to providers to meet your needs. You need to build a relationship with them so they know you and what your wishes are.

Another cost-saving effort is a narrow network that limits the providers you can visit within your community, so you might not be able to go to a provider/specialist you want to see if they are not in your network. If you go to a provider not in your network, your insurance will not cover the cost of the visit. So you will need to pay out of pocket. Paying out of pocket is ok, but you must set aside money to pay what is owed. Again, working with your primary care doctor and reviewing the list of providers in your network can help you choose a provider you can work with.

Another cost-cutting scheme insurance companies use is to offer high deductible plans. Some high deductible policies can be as high as $10,000.00 per year. This means YOU need to pay the first $10,000.00 before the insurance company starts to pay anything. Again, having savings to pay the deductible is important. Most people don’t and find themselves in medical debt.

There are many other ways insurance companies and employers use to cut their costs. They often need to be understood or clarified so that you, the end user, are not surprised that something you thought was covered is not, leaving you with a medical debt. The Patient Advocate Foundation has some essential tips you can use if you find yourself in medical debt. Here is the link

If you are not offered insurance through your employer, you can purchase individual health insurance. Individual insurance policies are costly. They are not easy to find and, again, hard to understand due to the complexity of the policies. Many people do not have an employer-sponsored health plan and cannot afford an individual policy. To address this problem, the government passed the Affordable Care Act in 2010. These policies are based on income – those with low income receive subsidized insurance. Many people have benefited from these policies since their inception in 2010.

There are other types of insurance people can take advantage of. For example, there is Military Health Insurance for active duty service men and women and their dependents. Veterans’ health insurance is available for those who have retired from the military and are eligible for veterans’ health insurance. Those not qualifying for these policies may be eligible for two United States safety net programs. Medicare and Medicaid. Medicaid is for people who fall below a certain standard established by the State they live in. The other safety net policy is Medicare. Medicare provides health insurance for those over 65, those who are disabled, and those with chronic kidney disease and a few other conditions. Children who do not have traditional health insurance are covered by the Children’s Health Insurance Program (CHIP), which provides health coverage to eligible children through both Medicaid and separate CHIP programs. States administer CHIP according to federal requirements. The program is funded jointly by states and the federal government.

As you can see, there are several choices, all with various qualifying rules and regulations regarding how the insurance is used.

What can you do?

  1. If you are an employee and receive healthcare from your employer or purchase an individual policy, read your member handbook. The member handbook contains much of what you need to know about your policy, how to use it, and what is and is not covered.
  2. You can also call your insurance customer service department. This number is usually on the back of your card. They are well-versed in the various policies they offer and can answer basic questions.
  3. You can also ask for a nurse case manager to help you find providers and the resources needed to meet your needs. This is a free service from your insurance company, so please use it. It can save you a lot of frustration. Usually, the Hospital Case Manager and the Insurance Case Manager work together, so ask your Hospital Case Manager to help you get an insurance case manager once you leave the hospital.
  4. Independent Patient Advocates are also in place to help you and your family navigate the complex healthcare system. Independent advocates are in place to help you. Depending on their expertise, they charge a fee for their services, usually around $75.00 and up. Their allegiance is to you and your family. They work in many areas, including addressing insurance challenges and care coordination. Many people have a Patient Advocate on retainer for the ‘what if’ situation. My advice is don’t wait for the emergency to happen – have a Patient Advocate on retainer so you have peace of mind.
  5. Some employers set up Flexible savings accounts that allow you to put money from your paycheck to offset costs to pay for out-of-pocket expenses.
  6. Talk to your employer about how your plan is working. Most employers want to offer a good policy for their employees, so sharing information on your experience with your healthcare insurance company is essential. If you get good care, let them know. If you don’t get good care, let them know.
  7. Using your voice will allow your employer to let the Broker know how the plan is functioning. They can inform the insurance company and register complaints or compliments with the provider relations department. Health Insurance is too expensive to accept mediocre services. Speak Up!
  8. If you call customer services and do not get the help you need, you can escalate the issue/questions to upper management within your insurance company. Don’t hesitate; that is what they are there for.
  9. Ensure you note who you talked to, what was said, and who is supposed to follow up.
  10. Be prepared to wait on hold. It can take time to get to the right person. Perseverance is critical when dealing with anyone within the health insurance company.
  11. Remember, you and your employer pay a lot for your health insurance policy. Using it to its fullest is essential. Your policy allows you to get preventive care services and address issues with providers as needed. Know the rules, stay within your network, and demand good service. That is your right!
  12. Speak up, be your best advocate, and learn how to use your policy to meet your healthcare needs.

This article gives you some insights into your health insurance and empowers you to use your policy to meet your and your dependent’s needs to keep you healthy.

Thank you for reading. Please comment or email me if you have any questions at

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