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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