Health Insurance 101
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Navigating the health insurance system on your own can be intimidating, but this podcast will teach you the basics of health insurance and share youth stories about navigating the system. Health Insurance 101 will dive into what health insurance is, what your coverage options are, paying for health insurance, and how to make the best use of your healthcare coverage. YE4C EB Member Michelle shares her story of navigating healthcare as a disabled young person.
To skip the basics of what health insurance is and what insurance pays for, jump to 7:57.
Listen to the first episode of this podcast: Navigating Healthcare as a Young Person.
Resources mentioned in this episode or used in the creation of this episode:
How to find a Healthcare Navigator:
Disclaimer: The information shared here reflects the opinions of the host and interviewee and do not reflect the views of the Interagency Working Group on Youth Programs.
Amber: Welcome to Youth Engaged 4 Change Radio, where we seek to empower and inform young listeners like you! My name is Amber, I use she and they pronouns, and I’m 23 years old. I live in Teller County, Colorado, and I’m an editorial board member with YE4C.
Today I’m going to be talking about health insurance and navigating its sometimes intimidating waters. For those who might not know, health insurance is a service that helps pay for your medical costs. Most health insurance in the US is provided by employers, with a portion paid by both the employer and the employee. Health insurance can be provided through your or your parent’s employer, something you buy on your own on the health insurance Marketplace, or even something provided to you by the government for often no cost.
During this episode, I’ll go over what premiums, deductibles, and enrollment periods are, and where to start when searching for health insurance depending on your living situation, age, location, and medical needs. I will also talk about how your health insurance may impact your relationships with your healthcare providers.
I’ll also have one of my fellow YE4C editorial board members, Michelle Kim, come chat with me about some of her experiences navigating health insurance as a disabled young person.
Before we dive in, I want to say first that for insurance know-how, there are really quite a few helpful and trusted resources online; I’ll be linking several of them in the episode description, along with a summary infographic of this episode – of course, you can also use search engines to help you out, but please be aware that often, insurance companies’ own websites will pop up first, and this can be biased information. I will also talk later in the episode about “health insurance navigators,” who can help you make your best health insurance decisions! My hope today is to give you some building blocks so if or when you do need to do some research, you don’t have to start at ground zero.
Additionally, if you already understand some of the basics of how health insurance works — like different sources of insurance, common payment structures, and so on — please skip to the time code in the episode description.
Amber: So anytime you go to get medical care — whether it’s going to your regular doctor, dentist, eye doctor, hospital, or urgent care — it does cost something. Some companies work with places that provide healthcare called insurance providers; these companies will help pay for some or all your healthcare costs. You might have seen commercials for popular health insurance providers.
The way that this works is that you pay the insurance provider a set dollar amount every month; that monthly payment is called a premium. The insurance provider then uses those payments from you and their other customers to help cover costs for their customers’ healthcare.
The amount of your healthcare that your insurance will pay for is sometimes called your coverage - although “coverage” can just also refer to having or not having health insurance at all - and it can be pretty different depending on what insurance you have. Whatever your insurance doesn’t pay for is called your “out-of-pocket cost or costs.” It’s a good name for it – it refers to everything you pay for yourself out of your own pocket. These costs can include deductibles, which I will explain very shortly, copays, which is the amount you might pay each visit to a doctor or pharmacy, or coinsurance, which refers to the percentage of all your healthcare costs that your insurance doesn’t cover.
Some insurances use what are called “copay only” plans, which means that you’ll pay a set amount any time you visit a specific type of doctor - for example, you might pay $40 every time you see an eye doctor who’s a specialist, while you pay only $20 every time you see your regular doctor, like your pediatrician or primary care doctor, and $500 if you have to go to the emergency room, and so on. These types of plans are actually fairly rare, but I’ve been on a few of them myself, so I wanted to mention them. For these copay-only plans, that’s all you have to pay besides your premium — you don’t get bills for anything else or any other amount because your insurance has paid for all the rest.
Amber: Other insurances pay a certain percentage of every medical bill up to a certain dollar amount each year — usually 80-100% of your medical costs for the year. However, before they cover that 80-100%, they often require that you pay a certain amount out-of-pocket. That’s called meeting your deductible – the term that I mentioned earlier. That amount can vary but would be a defined dollar amount per year for your plan; in other words, once you meet your deductible, the insurance plan kicks in with the plan’s listed coverage. Coinsurance works kind of similarly, except that you are paying alongside your insurer out-of-pocket; you might still have a deductible, or at least an “out-of-pocket maximum” amount that you pay each year, at which point your cost of coinsurance will probably go away.
A really quick note about meeting your deductible, too – some types of service don’t count towards that amount. So for example, your insurance plan might say that the copay for your annual physical exam from your doctor is not an out-of-pocket cost that goes toward your deductible. Say that copay was $40 – you’re not $40 closer to meeting your deductible, unfortunately.
You might only have certain types of insurance plans or payment types that you can get based on your situation. If you get your health insurance through your or your parent’s work, they will only be partnered with a certain number of insurance providers. If you use your parents’ or caretakers’ insurance, you’ll be limited to the plan that they can get, as well as what the plan will cover for you as a “dependent” and the person who doesn’t technically hold the insurance.
Sometimes income can affect the type of payment arrangement between you and your insurance — for example, if you have lower income, you might be eligible for Medicaid. Medicaid is government-provided health insurance. Another type of government-provided insurance is the Children’s Health Insurance Program, also known as CHIP. CHIP provides coverage for children up to age 18 and pregnant persons in low income families. If you’d like to find out if you qualify for CHIP or Medicaid, use the Benefits Finder on Benefits.gov and answer a few questions.
If you don't qualify for work-based or government-provided insurance plans, you can also search for private insurance coverage in the Health Insurance Marketplace through HealthCare.gov. You might also be eligible for a subsidy toward the cost of insurance depending on your household income level – this just means that the government reduces the price of your insurance premiums, basically, and you pay a much lower monthly premium than you might have.
The last thing I’d like to talk about as far as insurance plans is that you can sometimes get better coverage — lower costs on those copay-only plans, higher percentages covered, and so on — if you have a higher premium. This is common, where your insurance will have different “levels” of plans available, and usually they’re described in terms like bronze, silver, and gold plans, or something similar. You may have the option to choose from different levels of plans for work-based, private, or non-government insurances, too. If you get sick or injured often, or go to the doctor often for any reason, it might be worth it to pay a higher premium each month so that your out-of-pocket costs at the doctor are lower later, though often it ends up being the most cost effective not to do this. This is one of those choices that might be clarified for you if you talk to a health insurance Navigator, which again, we’ll be getting to in just a bit!
Amber: So I’ve been talking about healthcare coverage — but what exactly gets “covered” or paid for? Healthcare includes a lot of stuff, right? Because of this, insurance providers will sometimes separate types of care — you might even have completely different insurance providers for different types of care like prescriptions, dental care, and vision care, depending on the details of your plan.
Generally speaking, medical healthcare and mental healthcare often fall under the same plans and similar payment methods for insurance. So medical care — we’re talking about your doctor visits, emergency room or urgent care visits, physical therapy — anything that has to do pretty specifically with just your body and its health. And then for mental healthcare, we’re talking about therapy or counseling from approved providers, visits to psychiatric care facilities, or medication management with a psychiatrist.
If your insurance will cover any kind of medical or therapeutic equipment, like compression socks, walkers or canes, or chair lifts, then usually that falls under your main medical insurance, as well.
Two types of healthcare that are often separated from medical care under insurance are eye care and dental care — but only in some cases, which can be confusing. Generally, you can expect normal or routine care from eye doctors and dentists to be separate and covered under their vision or dental insurance. Sometimes you can even expect preventive services — care that helps to keep problems from happening, like wisdom teeth removal or eye disease screening — to be covered under that, too. However, when you go to more specialized eye doctors or dental specialists, like ophthalmologists or eye specialists, orthodontists or dental surgeons, or eye surgeons, that could end up being covered under your main medical insurance plan or not at all. It’s always best when going to anyone who provides healthcare to ask if it’s covered and if it’s going to be on medical insurance or specialized insurance before you go.
Amber: Welcome back to anyone joining us from the timecode jump.
Another service that can be separate from your main medical insurance is prescription medications. These can come from any pharmacy — not only big box, national retail stores, but sometimes hospitals or medical office groups have their own pharmacy, or there may be a local pharmacy in your neighborhood, or your insurance may cover mail-order pharmacy options. Sometimes you can get coverage for prescription medications through your regular health insurance, but you might need a separate card to give to the pharmacy you use. Some insurance companies even have specific pharmacies that they would prefer you work with to lower the cost of medications.
One really important thing I’d like to mention here is that sometimes it can save you money when you ask your doctor to give you a prescription using non-name brand – also called generic – medications. If you forgot to ask or if your doctor forgot to do it, you can also always have the pharmacy call your doctor and see if it can be switched to a generic - although be aware that you might have to go back and see your doctor in order for them to do this in some cases. Sometimes insurance will also simply prefer that you use the name brand medication and will cover it instead of generic ones - this is often discovered when your pharmacy tries to fill a new medication for the first time, and they should communicate that to you as soon as they find out.
There are also sometimes coupon deals that you can use for medications. There are apps that will search for the best deals on medications in your area, and you’re more than welcome to ask your pharmacy to tell you what the cost would be if they use insurance to help pay for it so that you can compare the prices. You can also ask your doctor when they want to prescribe a medication for you if there are discount cards available for that specific medication. Sometimes you can get name-brand medications cheaper for anywhere from three months to a year, just because they are partnered with your doctor’s company.
Amber: So insurance has three main places or ways you can get it if you’re not covered on a parent, caretaker, or spouse’s plan. Being on someone else’s plan is called being a dependent, and it means that the responsibility for paying the monthly insurance fees legally is not your responsibility; any deals you have with the person who actually holds the insurance are up to you, and that person. Just as a side note, you can stay on your parent or legal guardian’s insurance until you’re 26!
I quickly shared two of the other main ways to get insurance earlier, but just to recap — government-sponsored insurance is available to folks under certain income levels, and it comes in the form of Medicaid for those over 18, or the Children’s Health Insurance Program (known as CHIP) for those under 18 or pregnant persons in low-income families. Your (or your entire household’s) income level affects the types of coverage you may be eligible for under Medicaid or CHIP, and you can find out if you’re able to use it at Benefits.gov. You can also apply for Medicaid on HealthCare.gov and find more information for your state on Medicaid.gov.
You may also be able to get insurance through your work, depending on if they provide health benefits and you qualify to receive them. That’s something that should be explained to you when you start at each new job, and if it hasn’t been, you definitely can advocate for yourself and ask your boss or HR representative to explain it to you. A lot of the time, you can pay a lot less on insurance through your work, because insurance companies will give group discounts to companies and some companies might cover some amount of your monthly premiums.
The last main source of insurance is private insurance that you pick and pay for on your own — you can get it on the Health Insurance Marketplace. It’s an online service where you can shop for the insurance that best fits your needs and budget, and you can find it at HealthCare.gov. If you get insurance there, you’ll sign up using the individual company’s website and signup process — make sure you follow all instructions and provide your correct email address so you get all the information you need to make a decision.
No matter where you end up getting insurance, there are certain times of the year (usually in the fall) or times in your life when you can start it, or switch to a new plan. These are called “enrollment periods” (or “open enrollment”), and they vary based on the company and the year. Medicaid and CHIP enrollment is always open, though. Always make sure you look at when your enrollment period is for the insurance you want, and make sure you don’t miss the deadlines. The other time you can enroll for insurance is when you have a big life change — this can be changing jobs, getting married, having a child, moving, and so on. You often have to “re-enroll” or sign up again for your same insurance plan every year if you want to keep it, and some benefits might have changed, so make sure you stay up to date on letters or emails from your insurance company.
Amber: I want to talk briefly about options if you don’t have insurance or if you don’t have insurance that covers very much for you – the rate of uninsured people is actually the lowest it has ever been right now in the US, which is great news! However, it’s still 8% of the population, which is a lot of folks. Obviously, if you’re eligible and can afford comprehensive insurance, that’s great, and the content in this podcast will be super helpful for that.
However, if you’re not eligible, here are some potential steps to help you get coverage. First, if you are currently uninsured or underinsured, please consider finding out if you are eligible for Medicaid – or talk to a health insurance Navigator! There’s a link in the description for where to find a health insurance Navigator near you (or even online), and it can be super valuable to do this whether you already have insurance or not. They can help you figure out the best insurance provider and plan for your specific life circumstances. Medicaid enrollment and eligibility processes vary by state, but your state may have an online tool to help determine if you are eligible or help apply for Medicaid.
In addition to coverage options through Medicaid and insurance on the Health Insurance Marketplace, you can also look into healthcare options that work with your budget. Some providers have what’s called “sliding-scale pay rates,” where the amount you pay them on your own without insurance is determined based on your income. Most public health or community health clinics are sliding-scale pay based, for example. In fact, almost every public health or community health office or clinic will offer you services for that adjusted price, and they actually won’t ask you to pay any more than you can that day – even if that amount is none. They do not seek that payment aggressively later, either; it generally never even goes on your credit score as a debt.
Amber: I’m going to get into a little bit more of the complicated ways that insurance works and affects where you can go to get healthcare. First and foremost, I want to say — your immediate health is the most important thing. If you have a serious emergency that could threaten your life, it’s more important to get to the nearest emergency room that can save you or your long-term health than it is to make it somewhere that takes your insurance.
With that out of the way, let’s talk about insurance networks; being “in-network” for insurance just means that the healthcare facility (hospital, doctor’s office, etc.) accepts payment from that insurance provider in both regular and extreme situations, and at the same time your insurance provider has agreed that they’re willing to pay that facility a certain amount or percentage. This doesn’t necessarily mean that every single provider at the facility accepts your insurance (particularly in hospitals), but the No Surprises Act protects you as a patient from getting surprise medical bills because a provider at a facility didn’t accept your insurance. Most facilities now will have you sign that you acknowledge what this act means – if you want, you can read it on your own from the link in the description, or ask for a paper copy of it next time you’re anywhere getting healthcare. Basically, the act puts the responsibility of the facility to make sure that either: the providers giving you care take your insurance; or you know about the fact that they don’t and can choose not to have them treat you.
There are four major types of insurance plans in terms of where you can go and still get coverage. The first is called point of service or POS plans, where you can use out-of-network doctors and offices and still get some coverage, but you’ll end up paying more than if you stay in-network. Under these plans, you often need a referral to see a specialist, whether they’re in-network or not. (If you don’t know what a referral is, you can listen to the first episode of this podcast!)
Preferred provider plans or PPOs are almost the same as POS plans, except you are less likely to need a referral to see specialists. The increased cost for out-of-network providers is similar to POS plans.
There are also exclusive provider organizations or EPOs; under this type of plan, you can only get insurance coverage from places that are in-network. Even in emergencies, some care that you get outside of that network may not be covered by your insurance at all. A drawback to EPOs is that if they decide not to make a certain type of place that’s close to you available in-network, like a mental health clinic, you won’t easily be able to get that kind of care using your insurance.
Health maintenance organizations or HMOs are pretty similar to EPOs, except that EPOs will limit you to specific places you can go for healthcare, while HMOs will limit you to specific people — or providers — you can see. Sometimes it can be beneficial to have an HMO because under these plans they try to make sure that there are at least one or two in-network providers in your area for every area of health. This can help you have more well-rounded healthcare.
Amber: Like I mentioned early on, having insurance generally means you’ll have to pay a fee every month, called a premium. How expensive that premium is will vary based on the type of plan you choose. It’s important that you think about your budget on a couple of levels. First of all, of course, pick a plan that you can afford on a basic level. If the monthly premiums are too much for you to be able to afford your other bills or payments, then that probably won’t be a solid option. Also, look down the road — if there’s a plan that is slightly more expensive but that you can still afford and will help lower the costs you’ll pay when you get healthcare, that can be super helpful in the long term.
Something else to think about is whether to get insurance at work if it’s available, or maybe through the Marketplace instead. As I had mentioned, it can often be a lot cheaper to get insurance through your job. However, if you’re in a job that you might not intend to be in really long-term, or if you know you might move in the near future, things like that — you might find it better to have some stable insurance through the Marketplace that will travel through your life changes with you. There’s no single right choice when it comes to this, though, it’s totally up to you, and again, I can’t stress enough – healthcare insurance Navigators can be life savers for these kinds of choices!
You will find out how much your insurance has paid for your medical care in two ways: bills directly from the healthcare provider, and monthly statements and Explanations of Benefits from your insurance provider. It’s important to pay attention to all of these communications (whether you get them in the mail or online through email or insurance and healthcare portals) and make sure that everything matches each other and matches the plan you are supposed to have. Don’t just pay a medical bill without checking that your provider submitted it to your insurance correctly or ignore medical bills that you can’t pay. Sometimes you might get a medical bill before the billing office at the healthcare office has caught up on their communication with the insurance company. You also don’t want to end up paying for something that you could have appealed to have coverage for.
Making good use of your insurance once you have it can sometimes be hard, especially when you are trying to make healthcare decisions at the moment. First of all, if you have the opportunity, always research whether or not the doctor you want to go to accepts your insurance and is in-network if that affects your coverage. Most of the time, you can go on your insurance provider’s website, log in, and enter your city or zip code, and they’ll show you a list of providers that take your specific insurance. You can also do that in kind of backwards order — look up the doctor you want, go to their website, and find their “insurance” or FAQ link to see what insurances they accept. Always call the provider’s office to verify this information before you visit as websites may not always be up-to-date. Keep in mind those in-network vs. out-of-network options, too, if you have a POS or PPO plan.
Amber: Any time you see a new doctor or provider for the first time, or if you change insurances, you’ll need to give your doctor your insurance card so they can make a copy. Same thing at emergency rooms and urgent care — if you can’t make sure you keep a physical copy on you for any reason, a lot of the time a picture of the front and back will still work so they can enter in the numbers and verify your coverage.
I want to talk a little bit about what things insurance can limit as far as your healthcare goes, outside of just where you can go. One brief thing to talk about is birth control — some insurance companies, particularly ones that you get through your work, may require a specific separate insurance card in order to pay for some or all types of birth control at pharmacies. Again, see if there are discount cards or coupons available for you in these cases — if not, you can look at your local public health office or community health center for free and low-cost options.
Insurance providers can also limit the actual types of treatment, care, or procedures you can get that they will help pay for. Most times when a doctor — whether it’s your regular doctor, a provider at an emergency room, a psychiatrist, or whoever — needs to perform a treatment or test for you, they have to tell the insurance company ahead of time. The insurance company then decides based on what they know about your medical needs if it’s something that they’re willing to help pay for — this is called pre-authorization or prior authorization. It’s important to know what types of tests and treatments your insurance plan requires pre-authorization for so that you can ask your healthcare provider to take the steps to get it approved. For example, don’t assume that just because your doctor ordered a lab test that it’s covered by your insurance or that the doctor will automatically obtain prior authorization. It’s ultimately up to you as the patient and consumer to make sure the proper steps are being taken. This process can mean that sometimes your treatment plan has to change from what it originally was, and can often mean that it requires a lot more planning if you need an optional service, medicine, or test.
Pre-authorization can sometimes affect specific communities, such as the LGBTQ+ community, because things like hormone replacement therapy or physical alteration surgeries are considered optional services. If you are in this situation, some alternative options can be searching for doctors in your area that provide these services for a lower cost without insurance, or you can sometimes get letters from mental healthcare professionals to your insurance provider stating that these treatments are something you do need for your well-being.
The exception to this rule is in emergencies — an emergency room doctor won’t wait for permission from your insurance company to do something that will help save your life, solve current serious injuries, or keep more serious injuries from happening. This can happen a lot in emergency rooms because sometimes insurance companies take a while to approve requests. Basically, in this situation, the doctor will ask for permission from your insurance company after the treatment is done.
Whether you get pre-authorization or have to get your insurance provider’s permission later, sometimes they might say no — as I said, they get to choose what services they help pay for. This doesn’t mean it’s the end of the road for getting coverage on that treatment, though — you can ask your doctor to “appeal” the decision, or you can appeal it on your own, although doing it on your own can sometimes be difficult. When an appeal happens, the insurance provider will usually request and then end up with much more in-depth information about why you need (or needed) the treatment, and how it will be good for your health. I want to reiterate how important it is to pay attention to when prior authorizations are needed. It’s easier to appeal a test or treatment that has not been done than to appeal one that has already been performed and that you’re now responsible to pay for.
One big thing to know about both the pre-authorization and appeal processes is the insurance providers are not allowed to say no to treatments that help with illnesses or conditions you already had. These are known as “pre-existing conditions,” and they can refer to things like heart disease or history of heart attacks, diabetes, mental health conditions, chronic or ongoing pain, arthritis, and so on. It used to be that you could be told no for those kinds of treatments and it was completely legal, but it’s now not allowed under the Affordable Care Act. You might end up paying higher monthly premiums if you have a pre-existing condition, though, and that unfortunately is still allowed.
Amber: Alright now I am going to have a chat with Michelle Kim, who I introduced a little bit earlier in the podcast. She’s a disabled individual, and I am going to let her talk a little bit about her experiences and identities. And then we will chat about her experiences with health insurance itself.
Michelle: Yup! Just as Amber said. Hello, my name is Michelle, and I use she/her pronouns. So I am a young person, I am 18 right now, and currently I have three chronic conditions. Two of which are “invisible,” or the symptoms are not primarily externally visible I would say. And one of which is “visible.” I have a fatigue disorder that I use a walker or sometimes a wheelchair for. So I think it is easy to say that I have had a lot of run-ins with health insurance and the healthcare industry in general. And I have had some very interesting stories, most of which are positive, with how I have gotten care with the healthcare industry.
Amber: Thank you so much for sharing that and thank you for being here with me today. I really wanted to get your perspective on some of these issues. My first question is What has been the most encouraging thing about starting to navigate your health insurance coverage?
Michelle: I think the most encouraging thing about starting to navigate my health insurance coverage was knowing that I'd get access to medical providers who were there to help me. That's the main reason we need insurance — but knowing that I would get treatment from a care team who joined the healthcare field for a reason — to help others — that was huge in helping me gain confidence in knowing this is the right step to take, even if I’m not sure about a lot of things at first. I might not even be sure about what kind of symptoms I have. But I knew I was preparing myself to be in good hands.
Amber: That’s awesome to hear. I have had a lot of similar experiences in receiving healthcare myself. It really is just great to know that there is a lot of people in that industry that actually want to be there and actually want to make sure you are having the best time you can possibly have. What is the most discouraging thing about starting this type of navigation?
Michelle: There are a lot of potential discouragements that are very tailored to youth. Mostly because sometimes we don’t really know how to start off, or we don’t really understand the need for health insurance unless you already have pre-existing conditions. And even on top of that we are already navigating a lot of life choices, so looking at health insurance, maybe if you are in a place that you may not need as much healthcare right now, that is often times pushed to the side. But the main difficulty that I have seen with youth and how they navigate healthcare, is not seeing results come up straightaway. Sometimes for me as a low-income student I have to wait months for healthcare, but that was at the beginning of my journey. And once I got set up with a primary care provider, and then I got referrals for specialists, it was a lot easier to try and manage my visits. And I knew exactly what I needed to do in order to get to the provider that I needed to get to.
Amber: That sort of waiting around and jumping around can definitely be frustrating. I’ll reiterate what you said about primary care providers. It makes it a lot easier when you’ve got that one person that can kind of of guide you where you’re supposed to go. And in terms of insurance it can definitely be frustrating waiting around for them. But once they your situation figured out and approve what they need to approve, it can go a lot more smoothly. So my last question for you is, what are the top three tips that you have for people our age just staring this journey?
Michelle: So first of all I would like to give a lot of encouragement because health insurance is one of the primary things in your life that will stay constant. You will always need health insurance even when you don’t think you need it. Personally, from my experience three tips I have is know your health, mind your health, and keep going at it. So knowing your health kind of means knowing what kind of care you'll need most often. This can just be primary care, if you don’t need care that much. You know that you’ll probably just need general checkups every once in a while. For example, other things to think about are what kind of genetic or inherited disorders or illnesses that you might have or need preventative care for — especially for illnesses like cancer in the family and diabetes — I would say you really need to keep an eye out just to make sure that you’re staying healthy. If you have any preexisting conditions of course, you’ll want to make sure that it is covered. How frequently you want to go to the doctor — at the very minimum, it should be at least once a year for prevention purposes and just to make sure everything is fine. Unfortunately a lot of people just learn to live with some abnormal things that they just think is normal. And then once they find out that it is not actually normal, their lives can get a whole lot better because they are actually getting treatment. So even if you’re not really thinking that you don’t need any specific things, just always try and go for a checkup. Also if you'd like other care plans included, like dentistry, optometry, family planning, this is all important to know when you are looking at what kind of health insurance is good for you. So knowing what you need, and knowing what you could need.
Second would be how you find your health insurance. If you are employed, your company might provide health insurance for you. And it fits then you should take full advantage of that. For example, even if it is a basic plan, if it has all of your needs, then that’s awesome. Try and use it as often as you can. But you can also register for more types [of insurance] if you need different care that is not provided. Or you think it will just be good to have it. If you’re a young person, your parent or guardian might also have insurance that covers you through their employment or other organizations. And if you are in school, your college or higher education institution could have a student health insurance plan. Even if you can't afford to pay for insurance, there are still ways to get it. Registering for Medicaid or other government-supported insurance programs is critical even if you don’t think that you can afford health insurance. If you don’t think that you can afford health insurance, you are absolutely not going to be able to afford an emergency, hopefully which would never happen, but unfortunately they do. Like if you have a dental emergency, if your tooth is hurting a lot and you just need to get it checked. Things like that, small things, or bigger things like breaking bones or needed surgery. You never know when they are going to happen and you absolutely going to want some kind of coverage for that.
And then the last part is kind of mental, I would say. Knowing that you are taking a huge step in the right direction to making your life a healthy one, that is probably the most important tip that I can give is to keep that mentality. Understand that even if you're healthy now, it is critical that you have health insurance because you want to keep taking advantage of that health and retain that health for as long as you possibly can. And you want to know that you can successfully take care of yourself, or you will have needs to take care of yourself. God forbid you need it. And I personally think a lot of people might not completely appreciate their health until they lose it. And that is true for most people who have chronic conditions like me. I would say it is very difficult for some people to recognize that their health won’t always be permanent. So I would say just start appreciating a lot more the resources that are available to you. For example doctors and other providers, they really are there to help you. So I would say take advantage of all that you can and know that you doing this is what you are going to need to do to ensure success in your future.
Amber: That is all really awesome advice, Michelle. And I just wanted to thank you again for being here with me today. I really appreciate your perspective and I am sure our listeners will as well.
Michelle: Yeah of course! Thanks for having me. I really hope you all got some new information from me today.
Amber: You are allowed to have more than one insurance provider at a time — one will be main or primary insurance, and the other will be called a second payer or secondary insurance. This only applies to medical insurance — having medical and vision or dental insurance from different companies doesn’t count, because of what we discussed earlier about how strict vision or dental care includes separate treatments than medical vision or dental care. Sometimes it can be helpful to have two insurances, especially if you are a dependent on one insurance and the person holding the insurance is yourself on another — it can mean more of your care gets paid for instead of having to pay out-of-pocket. However, I will say that arranging payment options can become more complicated with more than one insurance.
It’s fairly common for people to have both Medicaid or CHIP coverage along with insurance coverage through their employer. Which insurance is the primary insurance can vary from state to state or based on individual situations, but Medicaid or CHIP will be the secondary payer or “payer of last resort” — meaning they will only begin to help with cost coverage once any and all other insurances someone holds have done all they can or will.
You can choose to receive healthcare without using your insurance just like you can for medications, which can be helpful especially if you are going somewhere that uses what’s called sliding-scale pay, where they base your cost on your income level. Doing this will rarely end up costing you less than using your insurance, but especially at community health clinics or public health offices, it sometimes can.
I also want to note for anyone listening who might need the information — information about all healthcare you receive as a dependent under someone else’s insurance can be seen by the person who holds the insurance. They may or may not be able to see the specific details, but they can usually at least see where you got care and the type of care it was. This means that if you are a dependent on someone’s insurance plan, they can see the records, even if you only partially pay through insurance or a request is made but never used. If you ask for your care not to be run through someone else’s insurance, those records will be subject to the privacy policies of your state and the individual healthcare provider.
A final unique situation to discuss is when you get injured at your workplace. Almost every state in the US requires businesses with one or more employees to carry workers’ compensation insurance, often called workers’ or workmen’s comp. These insurance providers help to pay for injuries or illnesses that happen on and because of the job — if you do get hurt at work, it’s important when you go to receive care for it that you make sure that the healthcare provider does not try to run your bill through your personal insurance. When using workers’ comp, if it’s the first time you’re getting care for something, you usually will have to follow up with the billing office for the healthcare provider after you’ve gotten approval from someone in the human resources department at your work.
One thing you should do whenever you begin working somewhere is find out where to access the list of providers that your workers’ comp covers. There will usually be one or two emergency care providers, one or two urgent care providers, and a small list of primary care providers and/or specialists. Workers’ comp can end up covering a range of care — from an emergency room visit to physical therapy to follow-up visits with a primary care provider, as long as you’ve gone to the approved places. If you’re in doubt about whether or not you should be using workers’ comp when you’re receiving or about to receive care, it’s better to assume that you will be. It may be a good idea to double-check with the medical provider, employer, and health insurance plan about coverage.
Amber: I have covered a lot during this podcast, and I hope that I’ve stressed enough that it’s important to do background research on your own or with a health insurance Navigator before making any healthcare or health insurance decisions because small details can be very different between providers or plans. However, you should hopefully now have the tools to do that research effectively and without as many initial questions.
Just to recap: you can get health insurance through your employer, by being a dependent on someone else’s insurance, by purchasing it from the Marketplace found on HealthCare.gov, or by applying for Medicaid or the Children’s Health Insurance Program, if you qualify. Medicaid and CHIP are always open for enrollment, and for other sources of insurance, you can wait for their yearly open enrollment period, or sometimes qualify to change insurance because of a life event. You can have more than one source of health insurance at a time, which can sometimes be helpful but can also be harder to navigate. If you get injured at work, you should check to see if you might be covered by your employer’s workers’ compensation insurance first.
Insurance for medical care, vision and dental care, and medications or prescriptions can sometimes all fall under different insurance coverage categories, or you may even need them from different companies. The type of insurance plan you have and where it comes from can determine what healthcare providers and facilities you can go to, and there are cases in which you can choose not to use your insurance to help pay for your care.
You or the person who holds the insurance will pay a monthly premium to keep the insurance and depending on the plan you may pay out-of-pocket expenses such as copays at each visit and/or portions of each medical bill up to a certain dollar amount each year for a deductible. Your healthcare providers may have to get permission from the insurance company for many types of tests and treatment, except in serious emergencies, and you can appeal the insurance provider’s decision about paying for that test or treatment. Paying attention to all your medical bills as well as your monthly insurance statements and explanation of benefits is critical so that you can make sure you aren’t paying more for your healthcare than you are supposed to under your insurance plan.
I wanted to give a big thanks to Michelle for letting me chat with her about her experiences today! Also, there will be links to many resources surrounding this topic in the episode description, along with a link to an infographic summarizing this episode for visual learners or just for quick reference. Follow Youth Engaged 4 Change Radio for even more content made by young people, for young people, and visit YE4C on Instagram, Facebook, or online at Engaged.Youth.gov. Thanks so much for listening.
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