Do You Know Enough About Your Health Coverage?

From the WebMD Archives

June 22, 2000 -- You pay a little extra each month so you can go to a doctor who is out of your managed care plan's network, and you assume the drugs he prescribes for you will be covered at the out-of-network rate, also. Maybe they will, and maybe they won't. Or maybe your primary care physician refers you to a specialist, and you assume since your in-network physician referred you, the specialist's services will be covered. Well, maybe they will, and maybe they won't.

If you're a little sketchy about what your insurance will pay for and what it won't, you're in the same boat as most people. Many adults are barely keeping their heads above water when it comes to understanding their health care insurance, according to a recent report in the American Journal of Public Health. But it's in your best interest to find out more, experts say.

"From industry research, it's clear that people who understand their coverage are more satisfied with their plan," says Susan Pisano, vice president of communications for the National Association of Health Plans in Washington, D.C.

"Getting the most out of your plan," Pisano tells WebMD, "is a matter of learning all about it. First, compare companies, plans, and benefits by reviewing brochures on file in your human resources department. Then, have your questions ready for on-site company representatives during open enrollment," Pisano urges. "And if you think of more questions later, call member services."

One managed care company goes a step further. "We offer classes for new members to help them gain access to the system," says Jim Anderson, a spokesman for Kaiser Permanente, which is based in Oakland, Calif. "We wish more people would take them, but member services is also available at most of our locations."

Because public policy discussions about insurance are often based on consumer surveys, and consumers aren't that knowledgeable about their insurance, the journal's article authors suggest that policymakers rely on other sources other than you when developing policies regarding health insurance.

"Since health organizations are a more accurate source of data, the public and private sectors must find innovative ways to share information," says lead study researcher David Nelson, MD, MPH, chief of behavioral surveillance at the CDC in Atlanta.

Here's why: To determine what people really know about their health insurance, Nelson randomly surveyed 350 adults in metropolitan, suburban, and rural Wisconsin. Survey questions, developed by a panel of experts, focused on insurance source and type. Responses were then verified by the participant's health plans.

Insurance source was classified as private (employer-provided or individually purchased) or public (Medicare, Medicaid, CHAMPUS, Veterans Administration, military, and Indian Health Service). Managed care was defined as "choosing from a list of doctors or using a primary care provider for routine care." All other types of coverage were defined as fee-for-service, which is typically the kind in which you pay out of pocket for health care services you receive and are reimbursed a percentage of that fee later.

Although 97% correctly identified their primary health plan, 12% were not aware that they had public insurance. Others were confused about whether they were covered by their own employer, or someone else's, and how long they were enrolled. Only 30% were enrolled in fee-for-service plans, but most of them thought they had managed care.

Vital Information:

  • A new public health report found most people know little about their health insurance coverage. Experts say those who understand how their policies work are more likely to be satisfied customers.
  • The researchers found nearly all of the study's 350 adults in Wisconsin could identify their health plan but were confused about the type of insurance they had and whether it was provided by their employer.
  • The researchers say health organizations may be better sources of information when surveying about insurance, as so many insured people don't understand their health coverage.