Navigating Insurance

Insurance can be so confusing, especially when it comes to figuring out privacy!
Here's some information to help.

Insurance: Accepted Insurance

Health insurance is something designed to protect you from large hospital bills, in case you get unexpectedly sick. The way it works is that you pay a small amount every month to the insurance company. Then, if you ever get sick and require healthcare services, your insurance company protects you by paying the majority of the hospital bill (which can get extremely expensive).

The Basics

Private vs Public
Health Insurance

In simple terms, the difference is who pays the monthly costs of insurance.

PRIVATE

Your parent or guardian pays an insurance company a premium, or a monthly fee, in exchange for the insurance company covering the costs of your medical expenses. In many cases, an employer may also pay a portion of this monthly cost to help provide their employees with health insurance.

PUBLIC

The government pays the premium. In many cases, you must meet state-specific criteria to be eligible for this type of insurance (see 'Medicare vs Medicaid'). In this type of insurance, you receive more privacy, because no one receives a list of all of the treatments and medications you might have received at the doctor's office.

Indemnity plans (also called fee-for-service or reimbursement plans) allow you to see any doctor you want, pay the doctor directly, then send the claim to the company where they pay you back for part of the total cost. These plans generally don’t pay for preventative care (like annual physical exams) and tend to have a higher monthly premium than other plans.

Managed care plans or employer-sponsored insurance (ESI) are plans where you get insurance through your employer. Health insurance companies negotiate contracts with certain healthcare providers to provide care for members at a lower cost. There are a few types of ESI plans:

Preferred provider organizations (PPOs) allow you to see any doctor you want but are more expensive as a result. You pay less if you choose a doctor in your plan.

Exclusive provider organization (EPO) plans offer a smaller network of doctors than PPOs, but tend to be more affordable than PPO plans.

Conventional plans are also on the expensive end of ESI insurance plans. Usually, you are not managed by a primary care provider, allowing you to see any doctor you want.

Point of service (POS) plans allow you to choose an in-network doctor for most care but also allow going outside of the network for specialists, which you will also pay more for. This plan falls in the middle in terms of the cost of ESI insurance plans.

High-deductible health plans (HDHPs) are typically the most inexpensive and offer differing amounts of choice in terms of which doctor you can see. Out-of-pocket costs for this type of plan are usually very high.

Health maintenance organizations (HMOs) choose primary care doctors who coordinate all medical care. The co-pay for this plan is fairly low, but you can only see approved doctors and hospitals, and cannot see specialists without a written referral. The cost of this plan is on the cheaper end of ESI insurance plans.

Types of Insurance Plans

Medicare vs Medicaid

Unfortunately, not everyone is guaranteed the right to health insurance in the United States. This leaves people unprotected and unable to pay for the health care they need. To fill these gaps in coverage, Medicare and Medicaid were established in 1965 as two publicly sponsored health insurance programs. These two programs focus on providing protection to the following populations:

*You may often hear the Affordable Care Act (ACA) get brought up with Medicaid. That is because the ACA expanded coverage of Medicaid significantly. Before the ACA, Medicaid only covered limited-income pregnant women and children (under the age of 19). Now, with the ACA, everyone that falls under a certain income is eligible for insurance coverage under Medicaid.

MEDICARE

For the elderly (65+) or those who have a qualifying disability

MEDICAID

For people with limited-income and resources*

Important Terms

Deductible: a set amount the policyholder (in this case, your parent/guardian) must pay to healthcare providers before the insurance will cover additional medical expenses.

Copay: a set amount the patient pays each time they go to see a healthcare provider (e.g. $30) after which the insurance company covers all remaining expenses from that visit.

Coinsurance: the percentage of healthcare costs the patient is responsible for paying after their deductible has been met (e.g. 30%).

Out-of-pocket maximum: a set amount the policyholder must pay towards healthcare expenses before the insurance will cover 100% of any remaining expenses.

"My parents have a United Healthcare policy that I am covered under which primarily sets costs based on copays.

When I go to my primary care provider for a sick/problem I pay $30. When I see a specialist (e.g. dermatologist, endocrinologist), I pay $50."

"My parents have a Blue Cross Blue Shield policy that I am covered under which primarily sets costs based on a deductible.

When I go to my primary care provider for a sick/problem visit, I pay a negotiated fee for that visit. I will pay a slightly higher negotiated fee for a specialist visit. Once my deductible (e.g. $1000) is met, I will be responsible for a portion (say, 10%) of that negotiated fee."

Insurance Card and EOB

An insurance card (see example on the right) contains a lot of important pieces of information about your insurance plan. Although cards from different insurance companies may not look exactly identical, they have same general information on them such as the insurance company contact information (top right corner in this example), policy number (ID #), group number, plan name, and pharmacy network.

Figure 1: https://blog.cdphp.com/how-to/understanding-health-insurance-id-card/

Explanation of Benefit (EOB) is a document that lists each procedure and health care visit that you had within a certain time period (monthly, biweekly, or quarterly). EOBs are sent to the primary account holder – so if you're on your parent's insurance plan, your EOB will be sent to your parent's address.

This is an example of what an EOB looks like:

Figure 2: https://www.wellmark.com/insurance-explained/your-benefits-in-action/how-to-read-your-eob

Maintaining Privacy

Many states, including Maryland, allow insurance companies to give your protected health information to the primary owner of the insurance policies, in the form of an EOB, such that the primary owner knows what and how much they are paying for.

However, it is important to recognize that you have a right to privacy with regard to your healthcare. The S.B. 790 Laws say that an enrollee (you) who is dependent on a parent’s insurance (the primary owner) are allowed to request confidential communications between you and the insurance company.

Basically, you can ask your insurance company to send the EOBs directly to you (rather than to a parent) which will keep all of your healthcare information private. Here's how:

Call your insurance company:

Use the number on your insurance card or Google the customer service line for your insurance company.

To learn how much privacy your current plan gives you, ask the following questions:

What do they include in their EOBs on a regular basis?
Do they detail every procedure and questionnaire you receive, or do they keep it private? (for example: will they show that you had a "routine screening" vs. "HIV screening")
Do they say the full name of the location you received services? (for example: "Planned Parenthood" vs. "Primary Care Checkup")
Do they write the reason for the visit within the EOB?
Will my parents see the full name of the medication or prescription I will be taking?
Even if I get privacy on my communications with the insurance company, can my parents still get access to my health visits if they ask the insurance company for it?

If you want to proceed with making your communications private, ask your insurance company the following:

Do you need me to fill out an insurance privacy form and send in via email, or can I request privacy over the phone?
Do you only send EOBs over mail, or do you have an online portal (where parents could see health information) in which I can also request privacy?

If you want MORE privacy than not having an EOB sent to your parents:

Talk to the insurance provider about using private and confidential language within the EOB (for example: not stating the location of the appointment, medication names, what procedures were actually done). While this might not always be possible, some insurance companies may have systems set in place to give you as much privacy as you need.

If your insurance company needs you to send in an insurance privacy request form:

Maryland's Insurance Privacy Blank Form

Maryland's Insurance Filled Example

References

(Health Insurance Basics (for Teens) - Nemours Kidshealth, n.d.; REQUEST, n.d.; The Girls’ Guide to Getting Some Privacy on Your Parents’ Health Insurance: Bedsider, n.d.; Understanding Your Health Insurance ID Card | The Daily Dose | CDPHP Blog, n.d.)