Navigating Health Insurance

Health insurance is a topic that few people want to discuss, but everyone should consider from time to time. In fact, having some basic knowledge of the subject is vital when making informed healthcare decisions.
We sit down with the pros to explore the ins and outs of the industry, helping you consider your myriad options. 

It’s important to know some basics about the types of health insurance that exist, and how patients access them. 

Many people obtain coverage through an employer. In this situation, an employer purchases a group plan that is then offered to employees. Sometimes, the employer will cover all or part of the monthly cost of coverage, known as the premium.

Kelly McEver, sales director for CommunityCare in Tulsa, points out that there are often rules around who is eligible for this coverage, typically restricted to full-time employees. It is essential to investigate the details of a plan through a current or potential employer. 

A plan offered through an employer is often the most cost-effective approach, but for those who do not have access to an employer plan, there are other options. It also benefits all insurance customers to evaluate different options periodically, especially if life circumstances change, to ensure they use the best plan for their situation.

When an employee with employer-offered coverage leaves that employment, they may qualify for COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage, depending upon the employer’s size. COBRA allows the former employee to keep their coverage, including any coverage they had for family members, by paying the full monthly cost.

“Typically, COBRA coverage is available for 18 months, and the covered individual can choose to end their coverage anytime during that period if they are eligible for coverage through a new employer or if they become eligible for Medicare,” says McEver. 

Another option for health insurance is to choose a plan through the federal government’s Health Insurance Marketplace each year. These plans, provided by insurance companies, meet specific criteria. It is essential to pay attention to deadlines for these plans, as enrollment falls during a specific window each year.

These plans come in a range of prices based on how costs are shared and may be more expensive than an employer-offered plan. But some people may qualify, based on their income, for tax credits that offset some of their monthly cost.

Medicare is the primary insurance coverage option for those over 65 and younger people with specific disabilities. This program, run by the federal government, has several parts. According to Medicare.gov, Parts A and B cover hospital costs and doctor visits, respectively. Additional parts of Medicare should be considered to cover other benefits such as prescription drugs. Those nearing age 65 should learn about how Medicare will work for them. 

Medicaid may be another insurance option for certain low-income families. This program is administered at the state level through the Oklahoma Health Care Authority. It is important to check this program’s citizenship and income level requirements.

Beyond basic health insurance, there are many types of supplemental insurance. This can include dental and vision insurance or options such as short-term or long-term disability insurance. These are offered through an employer or purchased by an individual. It is important to consider each of these and determine if they are right for you and your situation.

“Studies have shown that unpaid medical costs are the highest reason for bankruptcy for individuals and families,” says McEver. “Having adequate insurance coverage is so important to protect your finances.”

According to the U.S. Census Bureau, in 2023, 26 million Americans, or 8% of the population, were uninsured. This rate is much lower than in past years, but still represents many people. According to the Centers for Medicare and Medicaid Services website, CMS.gov, stabilizing care for an emergency condition cannot be denied based on lack of insurance at most hospital emergency rooms. Also, since the passage of the Affordable Care Act, the government no longer requires people to have health insurance.

However, there are options for those who cannot afford health insurance or lack the option of an employer-provided plan. 

“Medicaid may be an option for people who cannot afford insurance and have very limited income,” says McEver. “Pregnant women and families with children may also be eligible without having to meet the stringent income limits.”

The health insurance marketplace may also have options that will fit within a tight budget. For Oklahomans, this is administered through the federal program at HealthCare.gov. It is vital to research all the options, as well as the tax credit options that may apply and make the plans even more affordable.

Even those with health insurance can find themselves in difficult situations when a claim – a request for reimbursement from your health insurance provider for covered medical services – is denied. The National Association of Insurance Commissioners provides some insight into how to deal with this situation when it happens. 

First, a medical provider typically files a claim after service is rendered. However, a denial may also come when someone seeks preauthorization for a service – which means advanced permission to receive the procedure. After payment is made – or not – the insured will receive an Explanation of Benefits describing what was charged, what the insurer paid and what the patient is responsible for paying.

“If someone receives a notice of claim denial, their first call should be to their insurance company to confirm the reason for the denial,” says McEver. “Often, it is something as simple as an incorrect code entered by the provider, and your insurance company can work with the provider to get the correct information.”

If the denial still stands after ensuring all the submitted information is correct, there is a two-part appeals process, according to HealthCare.gov. The first step is an internal appeal. This is a review of the decision by your insurance company. Be sure to keep track of all related paperwork and any deadlines to appeal that may apply. HealthCare.gov also mentions that if the matter is urgent for your health, be sure to let the insurance company know this, and they will speed up the process. 

If necessary, and the denied claim qualifies, a second option is an appeal with an independent third party or external review. HealthCare.gov and the Oklahoma Insurance Department website can provide detailed information to help with this process.

Whether someone has health insurance can significantly affect their overall health. While many people experience differences in their social, economic or environmental circumstances, some insurance companies are working to make access to health available to everyone.

Blue Cross and Blue Shield of Oklahoma offer its Blue Impact Grants to support nonprofit organizations that provide sustainable, measurable programs covering five areas of need: economic opportunity and stability; nutrition; neighborhood and local assets like housing, transportation and access to physical activity; local health and human service needs; and optimal health outcomes.

“We recognize the role certain factors play in someone’s everyday life – having opportunities for a good-paying job, access to nutritious food and affordable housing, to name a few,” says Stephania Grober, president of BCBSOK, in a press release. “These grants directly target those barriers to health and wellness and support the organizations working to make an impact across the state.”

CommunityCare also works hard to ensure that everyone has the opportunity to be healthy, regardless of social, economic or environmental circumstances, says McEver. One of CommunityCare’s programs is the Social Needs Mobile Screening and Referral Program, which helps connect members with local resources for essentials such as food, housing, transportation, utilities and interpersonal safety.

“Our goal is to improve health outcomes, reduce healthcare costs and address health disparities for our members,” says McEver. “By identifying and addressing social needs, we can help our members achieve better overall health and well-being.”