Birthdays are supposed to be fun, right?
Cake, drinking with friends, and celebration! You’re not supposed to be on the phone for almost four hours, calling all your doctors’ offices, specialists, and new insurance company to get everything situated before your need another birth control refill.
Well, my 26th birthday is coming fast. I had the option of getting my “adult” insurance through my work a little early, and I thought, “Why not?” What followed was a three week nightmare of trying to get it all sorted out. Wasn’t the Affordable Care Act supposed to make this process easier?
I’m a little unlucky when it comes to medical issues as I suffer from an autoimmune disease that requires an IV infusion every eight weeks. Due to the type of medication I need, it required a pre-authorization from my insurance company. The difference in price with and without health care is honestly unimaginable (I don’t even owe that much money on my car), so my new health insurance was the only way to go.
Now I am three weeks past my refill, still waiting for all the doctors to get it sorted out, and hoping that through this mess of a transition I can maybe provide some insight into what other 26 year olds can expect when they reach this “adult” milestone.
Through my personal experience over the past couple of weeks, I present to you a ‘survival guide’ of sorts to getting kicked off your parents plan. Let’s hope your transition is smoother than mine.
Choosing your Healthcare Plan
Learning the basics of healthcare options was dizzying for me, as I needed to be specific about my coverage. Luckily, I had some insider knowledge from a friend who worked in healthcare and my mom (who had been dealing with my insurance needs for 10+ years).
Let’s start from the beginning… Does your job offer insurance? Hopefully, because of the Affordable Care Act they do; but if you’re working for a small company that has less than 50 employees, it is not required to offer insurance.
If you aren’t sure of your employment status (ie: contracted or employee), you might want to look into options through Healthcare.gov. The website is fairly easy to navigate and will offer you the most affordable options based on your income and health care needs.
There are a variety of plan types in the United States, but the four most common are PPO (Preferred Provider Organizations), HMO (Health Maintenance Organizations), POS (Point of Service Plans), and HSA (Health Savings Account – AKA High-Deductible Health Plans). I won’t go into the specifics of each, but here’s what you should look out for:
The Deductible
The deductible is a magic number that your healthcare provider will choose (between $1,500-$6,000 or more) that is their limit of how much you will pay before they start paying. Depending on your plan, everything before that amount (unless otherwise stated) is going to require you pay 100%. When you reach it, then the insurance company will start pitching in based on whatever criteria they decide. For example, they might pay 60% after the deductible is met, but you might still have to pay 40% (this is also known as co-insurance).
The Copay
A copay is a set amount that insurance has created for specific procedures. For example, I have a $30 copay for all in-network doctor visits. Instead of paying 100% (until I reach my deductible), I am only paying a fraction of the cost. Emergency room visit copays tend to be higher than a normal doctor visit, but paying $250 for an ER visit is considerably nicer than paying $2,000+. If you see a set copay, I recommend checking it out.
Prescriptions
This one is all over the place in terms of what is covered and what isn’t. The important thing about prescription coverage is to be aware of any fluctuations in cost. Some plans will list a selection of prices, like $15/$45/$75, and this normally translates to “generic/name-brand/specialty” refills. It might help to ask your doctor for generic brands (if possible) to save yourself some money. Ask your doctor if they are aware of any reimbursement programs for any specialty medications you take, too.
Still with me? There’s more terms and definitions scattered around the web. I would recommend checking out Healthcare.gov and WebMD for more in-depth explanations.
Turning 26 is a “Qualifying Life Event”
I’m sure you’ve all heard the term “open enrollment” floating around the office. The term refers to the time you are allowed to sign up for insurance. When I heard it, I panicked. I still had a few months on my parent’s insurance, but after that I would have to wait another 6 months before open enrollment rolled around again.
Fun fact: there are exceptions to open-enrollment! These are called “qualifying life events.” One of those exceptions is turning 26!
So don’t sweat signing up when open enrollment happens. Just let your HR or insurance company liason know when you will be aging another year on this planet, and they will be sure to get everything ready for you.
Bonus information: If your parents are insured through the military (TRICARE), you will lose your insurance at the age of 21 (23 if you are in college), but will be eligible to get TRICARE Young Adult until you are 26. Be aware!
If you have med refills coming up, get that new info in ASAP
Insurance companies have the final say in what they will cover, and for many newly insured adults that may mean your refills are now going to cost a fortune. For some reason insurance companies believe they know more than your doctor when it comes to treating your body (yes, I am bitter).
Nevertheless, I highly recommend going into your doctor as soon as possible to give them your new information. Also, take the extra step to go into your pharmacist and give them your new information. Despite the push in healthcare for shared electronic patient charts, we still aren’t quite there yet. Better to just cover your bases than to show up and find a bill for $300 for your prescription refill.
Insurance Companies are not helpful, but most Nurses are
In my experience, calling the insurance company directly is a nightmare. I get it, they are most likely working at a call center and dealing with mostly angry patients. They’re not going to have the patience to answer my questions. Plus, I’m going to be led through a series of repetitive personal questions before they can provide any information (it’s a requirement of HIPAA). I do not envy anyone sitting in their position, but I also don’t recommend ever calling them if you need to get some general information.
Instead, try to call your doctor or nurse and see if they can answer your questions. Often times the individuals in the billing department at your doctor’s office will know more about insurance questions than anyone at the actual insurance company. They’ve had to deal with almost everything.
Of course, you should call your insurance company if you need to give them new information, check a claim status, or check their coverage. If you do have to call them, try to remember to be patient. If you are angry, then ask to speak to someone that gets paid enough to be yelled at. They will appreciate it, and so will you in the end.
Health Insurance and Taxes
If you decide, after all of this, that health insurance just isn’t worth the effort, then be aware you will have to owe money when you file your taxes if you are not insured. That’s right, you have to pay more if you don’t want insurance. Yes, this part of the Affordable Care Act is pretty ridiculous. Luckily, there are a few exemptions based on your state if your limitations are finance related.
Through all this I hope you are able to find the right healthcare provider for you. Considering the amount of stress I have had to experience in my own efforts, I know the experience is not in any way easy or fun. But, hey, you’ve survived 26 years on the planet now! You’ve got this… Welcome to the final stage of adulthood!
