Top tips for using your new Obamacare health insurance

With Obamacare gearing up now in 2014, here are some suggestions that may help you transition to your new health insurance plan. With some luck, these tips may save you some headaches and bills in the future.

BEFORE you try using your insurance, you’ll want to do the following….

If you haven’t yet received an enrollment card, verify through your selected insurance company that you are enrolled and for which plan. If you have no insurance card, request that they give you your ID number or other identifying data to show that you are enrolled. Keep that info with you at all times. When you get your ID card, again, keep it with you.

Check when your first payment is due and pay it on time.

Use the insurance company’s website to locate a doctor who is in your particular plan. You may need a PCP (primary care physician), for adults usually an internal medicine of family medicine doctor. Often, these are the go-to doctors that you need to see first before you can get to see a specialist, if you need one. Your insurance plan should have a list of PCP doctors available to you in your particular plan.

NOTE: Just because you have Insurance X does’t mean that all doctors affiliated with Insurance X will take your particular plan. You may have an Insurance X Silver plan. Some Insurance X doctors may take Insurance X but only the GOLD plan. When you’ve picked a PCP, call his office and verify that he is taking new patients and that he, indeed, DOES accept your particular insurance plan. Often insurance companies don’t update their Web site physician lists frequently. The doctor you’ve selected may be listed in the plan on their Web site, but may have opted out at some time in the past.

Doctor via Shutterstock

Doctor via Shutterstock

Once you’ve selected a PCP and verified the insurance information, you’ll probably need to make an appointment. The doctor will want to examine you, see your previous medical records, your medications, get your past history, labs, imaging studies, etc. If you have a deductible, you may have to pay for this visit out of pocket until your deductible is met. But this is a very important first visit. He may need to refer you to specialists to take care of some complex medical problems, for example. He’s not going to want to do that till he examines you and reviews your records. So set up an initial appointment. When you go, take your medications with you and any medical records from previous doctor that you’ve seen.

Another reason to get a PCP quickly is that, in the event of an illness that causes you to go to an Emergency Room or urgent care, your insurance may require you to contact your PCP to let him know that you have gone to the ER. If you don’t do this, you may need to pay for your ER trip totally out of pocket. But, in any case, if you DO develop a serious medical problem or think that you have, go to the ER regardless of whether you’ve selected a PCP or not. Then notify your insurance company ASAP what happened. They may have an alternate procedure for you to use in that circumstance. They may be less cooperative if you’ve had their insurance for a few months and have never gotten a PCP.

Also, the PCP you select for you may not be the right one for other family members on your plan. You may need a doctor who serializes in adult medicine. He wouldn’t see your children. So you’d need to get a pediatrician or family medicine doctor for them.

Check with your insurance company to see which pharmacies accept your plan. Your new PCP may want to know which pharmacy you’ll be using. Make sure that the pharmacy you select is in network with your insurance plan. The same will probably hold true if you need to have imaging studios (e.g., CT scan, MRI, etc.), physical therapy, etc. Not all will accept your particular insurance. Check with your insurance company to see if the site you chose is in network.

Make sure that you look over your policy to see what your financial responsibilities are. What is your deductible, and what outlays apply to that amount? (And find out what a deductible even is.)  What are the copays or coinsurance for a PCP visit? For a visit to a specialist? What are the copays for medications? These can vary. Which medications do they even cover, and for how much?  For on-formulary generics you usually pay less. For brand name drugs, you’ll pay more. For drugs that may have limits on them or require authorizations, you may pay still more.  And some drugs most certainly won’t be covered at all.

When you’re looking over your policy, see what kinds of preventive services you may be eligible for. These are things that are done to keep you well or to prevent you from becoming ill. Vaccinations, yearly routine physicals, weight management, smoking cessation and others may all be covered.

Your insurance company is the place to start. Talk to one of their customer service personnel and get the answer you need. I suggest that you always write down your questions and the answer you’re given along with the customer service representative’s name, plus the date and time of the call. Health insurance is complicated. I’ve sometimes gotten three different responses from three different customer service representatives about the same question. In that case, I asked for a supervisor and had her explain exactly what the company’s policy was and asked to have that faxed to me for reference.

Doctor via Shutterstock

Doctor via Shutterstock

You can also access the insurance company’s website to get your questions answered. However, two caveats. One, if there’s a problem with the information you got from the Web site, you have no fall back defensive position. You can’t say that you spoke to Mr. Smith on January 2nd at 3:15 PM and he told you x, y and z.  It’s very easy for the insurance company to just say that you misunderstood the information on the Web site. And that may leave you with a substantial bill. Also, as I mentioned previously, some insurance companies don’t update their Web sites frequently, may not edit and proofread them well, may be difficult or confusing to use, etc.

Here’s a good site that has some useful information and links that can help you with some specific problems and questions. Even though this link is through AIDSblog, the information is available and useful for everyone with or without AIDS. The links provided there are from Health and Human Services.

Happy New Year, and good luck with your insurance and good health!


(I’m told that in order to better see my Facebook posts in your feed, you need to “follow” me.)


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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  • Sam_Dobermann

    Wrong! It is covered and newly so on Medicare. And it should cost $160 so if you are told more you are being ripped off. Avoid that place/person.

  • Sam_Dobermann

    Not so. What about no cost, no deductible preventive care; checkups, tests, flu shots and other vaccinations, mammograms, etc.?

  • Sam_Dobermann

    What makes you think that all doctors would opt into the single payer system? What about a split where the ultra greedy doctors split off and only serve those outside the “government system. The well to do could just “visit” the single payer system if and when they needed real expensive treatment — or not at all.

    Furthermore do you really want Congress calling the shots on your health care? For one example — no federal money for abortions vs private insurance that covers them. They could limit choices for contraceptives, etc etc etc….

  • docsterx

    From the CDC: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm
    Specifically:

    “Recommendations for Use of Zoster Vaccine

    Routine Vaccination of Persons Aged
    >60 Years

    ACIP recommends routine vaccination of all persons aged
    >60 years with 1 dose of zoster vaccine. Persons who
    report a previous episode of zoster and persons with chronic medical conditions (e.g., chronic renal failure, diabetes
    mellitus, rheumatoid arthritis, and chronic pulmonary disease) can be vaccinated unless those conditions are contraindications
    or precautions. Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster
    from developing PHN, or to treat ongoing PHN. Before routine administration of zoster vaccine, it is not necessary to
    ask patients about their history of varicella (chickenpox) or to conduct serologic testing for varicella immunity.”

    There ARE other reasons that shingles vaccine wouldn’t be given, e.g. severe immunodeficiency, etc. but all of the info is in the article in the link above.

    If you don’t have those conditions and are 60 years old or older, talk to your doctor or county health department.

  • Nathanael

    I can’t get the shingles vaccine — never had chicken pox.

    I’ve been wondering what the chicken pox booster schedule is if any — nobody knows yet. Sigh.

  • http://calgarystatefarm.com/ Calgarystatefarm

    These are all great tips!

    Ted Yan

  • http://www.swift-codes.org/ James@ swift-codes.org

    And then, send a letter to your Congresscritter demanding single-payer,
    universal healthcare — so you don’t have to jump through all these
    hoops just to get to see a doctor.

  • http://www.rebeccamorn.com/mind BeccaM

    BTW, thanks for the advice to call the provider if the insurance card hasn’t been received yet.

    I completed my enrollment in early November, received the welcome letter, sent in the premium and later confirmed that the premium payment check had cleared. But as of this week, no card. So I called, spoke with a very nice young fellow who noted that while I was indeed enrolled, no card had been ordered for me. (Probably because I was one of the earliest successful enrollees.)

    Anyway, also following your suggestion, Mark, I asked for my patient ID and group number, so that I at least have that much.

  • yassine
  • Whitewitch

    Ohhh so sorry – I thought Shingles was one of those vaccines you didn’t get until you were over 55. My bad.

  • docsterx

    The comments I made above are concerning the shingles vaccine.

  • Whitewitch

    Ambassador it is.

  • http://adgitadiaries.com/ karmanot

    Thanks WW. I’m going into hiding now. But, ambassador to Japan would be nice. :-)

  • Whitewitch

    Thanks Doc…but I was thinking more about the Shingles vaccine….specifically.

  • Whitewitch

    I know I know…what is an oxymoron?

    Did I win?

  • nicho

    Strong democrats — jumbo shrimp — military intelligence

  • Whitewitch

    I say we draft karmanot and you!!!

  • http://www.americablog.com/ Naja pallida

    I’d be happy to help elect some, if some would only run. If only we could simply draft candidates.

  • docsterx

    There are continuing studies to see how long antibodies are maintained in the person vaccinated. Based on those studies, it may turn out that a booster shot could be necessary at some point sometime after the initial vaccination. But that’s unknown at this point. It seems to be more effective the younger someone is when the vaccine is given.

  • docsterx

    It depends on your plan as to whether or not it’s covered. Some cover it for those over 60 years old.

  • Whitewitch

    Where are you finding these strong Democrats?

  • Whitewitch

    That’s okay – I have heard conflicting things about the shot…like it is only good for a wee bit of time…and that it might not be effective if gotten too early or too late.

    Maybe Docsterx might know.

  • Whitewitch

    That is wonderful Drew2U….I hope it is so….Happy New Year.

  • Whitewitch

    I don’t agree with owning ugly terms that people use – in order to “own it somehow”. Sorry….it is the ACA or PPACA…and once people start using that term it will take away the sting and you will find more people signing up as well.

  • Whitewitch

    Then use both until People Do UNDERSTAND…you are not helping when you keep referring to it as Obamacare….it is like people that use the N word to try and make it okay and remove the negative from that ugly term. No RWNJ or Republican is using the term to help people.

  • Hue-Man

    What is the risk that there won’t be enough doctors to act as PCPs, particularly in smaller cities/towns?

    Ignoring that I’m in a single-payer system already, I checked to see how many doctors are taking new patients in my burg of 85,000 people. The result from the provincial website – two. One appears to have moved from a different town in the province and a second whose name and languages spoken suggest he was trained outside Canada.

    It seems the risk might be higher generally in the U.S. with networks which limit patients’ access to a subset of doctors. If I were in the American system and without employer coverage or Medicare, my conservative nature would have me shopping for a new PCP tomorrow morning if I didn’t already have one, just to be safe!

  • Drew2u

    “Obama cares”

    I agree with owning it. Take it from being a slur (because other than it being a system for the health insurance companies) to being proud for what it does (despite being a Republican plan in the first place).

  • Drew2u

    Look at it this way: my current plan has a deductible of $7500. One of the ~$30/month plans is $700.
    As soon as I hear back, I’m going to sign up ASAP! Happy New Year, indeed!

  • http://adgitadiaries.com/ karmanot

    The shingles vaccine is not covered and costs nearly three hundred dollars in these parts.

  • http://AMERICAblog.com/ John Aravosis

    Yes, I chose the photos :-)

  • http://AMERICAblog.com/ John Aravosis

    I decided a while ago to own it.

  • docsterx

    Good points, thanks!

  • docsterx

    I thought that they might be able to give you some guidance from the main number as to what to try next.
    Excellent, hope it works out!

  • docsterx

    Unfortunately, “Obamacare” has become part of history and English. Also, many people don’t know it by PPACA or even ACA.

  • Drew2u

    That’s the main website number, lol
    But I just got off the phone about 5 minutes ago and I think I may have it all set. I just have to wait for a confirmation phonecall within a couple of days.
    As it stands, I’m looking at being able to get covered for less than $30/month for a silver-level plan! Totally worth it!

  • docsterx

    Drew2u,
    Not sure if these will help, but take a look at this link: https://www.healthcare.gov/what-if-i-have-new-medicaid-or-chip-coverage/
    and give this phone number a try: 1-800-318-2596.

  • Drew2u

    *raises hand* I’ve been at this since October.

  • Monoceros Forth

    For the love of God, please stop using that term “Obamacare”. Here, of all places!

  • Monoceros Forth

    I’ll vote for that. I mean…I can accept on an intellectual level that the ACA is some sort of improvement. Seriously, though, if the whole point of this health care “reform” was to throw up as many intimidating hurdles as possible between citizens and the medical treatment they need, they couldn’t have gone about it any more effectively.

  • nicho

    And then, send a letter to your Congresscritter demanding single-payer, universal healthcare — so you don’t have to jump through all these hoops just to get to see a doctor.

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  • Drew2u

    I signed up back in October, told I was going to get Medicaid, then my state cute medicaid eligibility AND is holding off processing forms until March – which means my form is in limbo between Federal and State.
    Only since Monday were I able to contact someone at the Federal level who said she cancelled my form so I could sign up for insurance. As of this morning it’s still there and I have more phonecalls to make.
    I’d love to sign up for health insurance through the market, I really would!

  • http://heimaey.us/ heimaey

    Cute nurse!

  • bkmn

    To add to the suggestions – once you have an appointment to see your PCP, ask about immunizations. It is not too late to get the flu vaccine for this winter season and if older you may want to get the pneumonia vaccine or shingles vaccine.

  • Indigo

    Good advice all around. I suspect that our population has grown used to the walk-in clinic and emergency room method that the idea of have a primary care physician might seem like an unnecessary first step. Actually, it’s essential to long term health care. I hope that message gets out.

  • S1AMER

    I’d add another bit of important advice: Urge everyone you know who does NOT have insurance to sign up ASAP — in addition to helping themselves, they’ll be helping everyone, ’cause the more people helped by the law, the harder it will be for Republicans to destroy it.

    And for the future health of the ACA, and of everyone in America, vow to work this year to elect strong Democrats!

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