Most people don’t think about healthcare coverage until they have to. You’re healthy, things are functioning, so what’s the point in reading policies? However, there’s no need to use the manual after your house burns down to the ground.

There’s a lot to healthcare coverage (especially Medicare) that requires timely attention, but also many facets that are far more crucial than others based on what you’ll actually use.

When It Matters More Than You Think

When people are in the middle of a health crisis, they’re already under stress. They’re in pain. They’re scared. And they’re fatigued from far too many appointments. It’s truly the worst time to discover that the doctor failed to submit a pre-authorization request for the prescription she recommended, the treatment he prescribed isn’t covered, or they are even at a facility that doesn’t do things under their specific coverage plan.

People find out all the time that their services aren’t covered – and it’s not due to fraud. People believe health insurance works as a credit card – show it at the front desk and everything will be taken care of. Instead, insurance is like a complicated contract with a million if/then clauses.

But if they had done their research and understood their coverage beforehand, the ways they’d have to go about getting help might be simpler than just hoping for the best during such a stressful time.

The Most Common Complications

There are a few avenues where people get tripped up more often than not. First, durable medical equipment (DME). This includes wheelchairs, oxygen equipment, and mobility aids. All seem simple enough; if the doctor says you need one, shouldn’t it be covered?

Not necessarily. For example, Medicare requires certain measures for something to be deemed “medically necessary.” For a walker, you may need documentation from your provider that specifies your mobility is limited enough to interfere with daily functioning. Your doctor must document various diagnostics codes; you might be required to try out other less effective options first; and if you’re wondering does medicare cover walkers, it’s only possible if these guidelines are met.

Second, inpatient versus outpatient medical care. This sounds easy enough to discern, but hospitals sometimes keep people under “observation” status as opposed to formally admitting them. Same room, same level of care – completely different rules regarding billing and ability to receive subsequent care through rehabilitation covered under the same roof.

Finally, networks. Most people understand they must use “in network” providers; however, what happens when an in-network provider refers you to an out-of-network specialist? What happens when you’re in-network at a hospital but the anesthesiologist isn’t? These happen more frequently than one would think.

What Really Matters

Insurance is worded in a special form of torture where everything sounds equally important but is not.

What is most crucial? Your deductible and out-of-pocket maximum should be numbers that you have locked away. The deductible is what you need to pay before insurance kicks in; the out-of-pocket maximum is the most you’ll pay per year for it to be a wash after – or your insurance covers everything for free after that. If you have any serious disorders/issues, it’s likely you’ll hit both numbers anyway so make sure to have them on hand.

Your copays versus coinsurance. A copay is a set amount you pay (such as $30 for a doctor’s visit), whereas coinsurance is a percentage (for example, after the deductible you might pay 20% of the visit). Copays are great for predictable routine services; however, surgery and hospital stays could add up fast as that 20% could mean hundreds or thousands of dollars post-recovery.

Your insurance policies through your employer may have prior authorization requirements which means you have to get permission before certain treatments/tests/medications are provided. This can be obnoxious but failing to deliver can mean you’ll pay full price for something that would have otherwise been covered if the paperwork was completed first.

The drug formulary works similarly. Every insurance provider has levels of medications they cover by tier and whether or not they’ll charge anything. Generally, generics cost less than $10; however, if you like name-brand medications – and they aren’t covered – you’re looking at $200+ sometimes. Especially after your doctor needs to write a recommendation.

If you’re on Medicare or about to get Medicare, there’s also an entirely different entity where coverage applies.

Original Medicare includes Part A and Part B which cover most guidelines for hospitalization and doctor’s visits; Part D covers prescription drugs – but there are gaps. This gap is often filled when people elect Part C Medicare Advantage plans through an outside vendor; although this tends to include additional dental and vision benefits, plans often have networks and limited doctors.

Medicare also has enrollment periods. Fail to enroll during your window, and you’ll pay higher premiums forever; want to switch plans? There’s only specific windows for that too.

And who doesn’t think that just because a physician recommends something through Medicare it’ll be covered? It won’t unless it follows many stipulations which limits documentation and healthcare coverage.

How You Can Actually Learn This without Losing Your Mind

You won’t be an insurance professional by any means – but you’ll at least know enough information about the healthcare coverage to save yourself from unnecessary complications.

Know what’s covered based on what you already use – prescriptions, medical equipment and specialists – and what isn’t covered (if you’re engaged with your current doctor already).

Call your insurance provider (you’ll likely want to record this information) with specific questions when calm – “If I were to go to the ER today, what would I have to pay out of pocket?” – and ensure you get answers.

Check the provider directory for any specialties – in case you need more than just your family physician.

Review your Summary of Benefits; it will contain all the information about the healthcare coverage – but shorter than the full policy.

Finally, keep a file – paper or digital – with your insurance card, your highlights of coverage basics, and any numbers needed for convenience so when something happens, you won’t be scrambling.

The Bottom Line

No one wants to deal with insurance. It sucks. But four hours now could save you so much devastation later when needing it most.

You don’t have to know every detail – but know enough so that you can catch any major problem beforehand should it escalate into something worse.

It’s like making sure you have car insurance before getting in an accident – not after. The policy won’t change – but your ability to navigate it properly surely will.

Healthcare coverage is complicated enough without adding insurance confusion to the mix when you’re already sick!