Demystifying health insurance

It truly shouldn’t be this hard.

Credit: Glenn Carstens-Peters on Unsplash

Welcome to Solicited Advice, our weekly column that celebrates the helpfulness in health. Because in a world where strangers at the grocery store love to tell you that a specific brand of magnesium will indeed “cure” what ails you (it probably won’t, so sorry), we’re all about passing on our lived experience in a way that makes your life a little better. Are we experts? Nah, not really. But we’re great listeners who have perfected the art of pillow screaming. Let’s get into it!

I live in the U.S. and dealing with health insurance — no matter the provider or plan — is probably one of my biggest stressors. Any tips for navigating the endless calls and claims?

Ash: I consider myself very fortunate that while I’ve had my fair share of tests, procedures, and more (oh my!), the insurance providers I’ve carried throughout my life — well, until fairly recently — have not required more than a single phone call to address any issues. However, since I got laid off over the summer, it’s the first time I’ve had to fully navigate the process since it’s commonly expected that your health insurance goes through your employer in this country. I am just getting into the weeds in trying to really navigate this system on my own, and could use all the tips and tricks as I trudge through it all as well. Kat? Jess? Skyler?

Kat: If you don’t already request them, itemized bills should be your new best friend. Whenever I have to call my insurance provider, having the services and diagnostic codes laid out for every. single. piece. of the appointment, treatment, or surgery has saved me a lot of back-and-forth. (Bonus tip: Learning more about the ICD codes associated with your conditions is really helpful for self-advocating as well as your general health care knowledge. It’s helped me see how specialists are framing my care externally, and it’s actually how I learned more about my physical therapy consult and treatment plan.) My other big piece of advice, especially if you’re pursuing insurance outside of an employer, is to figure out your biggest pain points in managing your health, and choosing a plan that solves for them. For example, I chose to forgo some cheaper copays by signing up for an insurance plan that doesn’t require any referrals for specialists. I’m constantly expanding my care team, so removing that roadblock has really sped up how quickly I’m seen (and one time even demonstrably changed how soon I was able to get surgery).

Jess: I don’t recommend doing it how I do it, which is basically avoidance. In the past, I’ve done all the things — had good insurance, requested itemized bills, kept allllll the notes, etc. — and it still felt like a nightmare treadmill. Unfortunately, we live in one of those red states that didn’t want to accept the Affordable Care Act, and my partner’s employer-offered plan is largely pre-ACA coverage (a so-called “grandfathered” plan which is expensive, difficult to use, and ultimately tends to cost more to use it than being uninsured). But because they offer it, we aren’t eligible for the marketplace or any kind of assistance. We do currently have separate dental insurance via COBRA, and that is enormously helpful. It’s really good coverage (as it should be, because I was paying out the nose for it and medical while employed at our former place of work!), and so I mostly use CareCredit, ignore the explanation of benefits (EOB) statements, and only call if there’s an unexpected balance or bill. I do keep notes about this correspondence in my phone (date, what number I called, who I spoke to, what questions I had, what answers they gave) to reference later.

In short, navigating insurance is anxiety-inducing and scares the hell out of me due to past experiences. I want universal health care for all like yesterday (or decades ago), and I play the avoidance game unless something absolutely requires my attention. Again, I’m not recommending this tactic, simply being honest. 😅

Skyler: There’s so much I want to say — OK, scream into the void and at those who hold decision-making power — about the United States health insurance system. Navigating this system reminds me of preparing to take the SAT: You spend lots of hours and money trying to learn how to take the one test and speak the test’s language just to gain admittance to something, and… that’s it.

Insurance is unfortunately a necessary evil for most people — especially for those of us with multiple mental and physical health conditions. Depending on how you look at things, I’m very fortunate to be as familiar as I am with the system. Medicaid and I go waaay back; I’ve seen the inner workings of Medicare; I’ve applied for financial assistance from several hospital systems across multiple states (actual fun fact: nonprofit hospitals are required to have a written financial assistance policy (FAP) and make it publicly available, so it doesn’t hurt to apply for assistance or look into payment plans!); the list goes on.

All this is to say that you don’t know what you don’t know, and it takes a lot of time and struggle to learn how to navigate the world of health insurance. Although I’ve never enlisted the services of one myself, there are professional patient billing advocates (also called medical billing advocates) out there if navigating the financial side of health care feels especially overwhelming or is getting in the way of you receiving the care you need. Hospital systems, insurance companies, and VA facilities (the VA actually has its own Patient Advocacy Program) usually have advocates who will help you free of charge. There are also billing advocates who have zero affiliation with any institution, but these folks charge for their services. If you live with a chronic illness or other long-term or debilitating condition, there are many nonprofit organizations out there — such as the Patient Advocate Foundation and Good Days — that’ll assist you for free.

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