A quick guide to understanding health care

Staff Writer
Columbus CEO

ATLANTA -- It's open enrollment time for millions of Americans. And while many are going through the more routine process of re-enrolling for company-sponsored programs, others are navigating an often-confusing private market that now includes government-run exchanges.

Even people who have insurance may not be entirely clear on how they should approach their company's open enrollment now that the Affordable Care Act is in place.

''Empowerment and education are the key to good service," says Dr. Felicia Wade, an Atlanta-based physician and author, noting the frustration that many people feel as they face delays and confusing terminology.

Whatever your situation, Wade offers five quick tips for understanding your health care policy:

Know what is changing. If you are renewing existing coverage, be sure to look very carefully at what is different, says Wade. Some people may find they are being rolled to a more detailed plan. Do a comparative analysis so you will know what you have. If nothing is changing, then you are fine.

Understand the terms. Make sure you understand what a deductible is (the amount you will pay before your benefits kick in) and the amount of your deductible. Other important terms are "out-of-pocket maximum" -- the most you pay during the period of your policy before your insurance pays 100 percent of the allowed amount and "co-pay" -- the fixed amount an insured person pays everytime you see a doctor. "If you know those three terms you can have a basic conversation with your insurance provider over the phone," says Wade.

Don't overlook details. It's not easy to think about all the things that could happen, but now is the time to make sure you understand the details of things like emergency room visits, says Wade. "Many people who have never had insurance have used emergency as a place to go for primary care. It is important when you get a health plan to know what that cost is going to be," she says.

Know what preventative services will be covered. The new health care act requires coverage for a lot of preventative services, says Wade, including blood pressure, depression, obesity and immunization and vaccines. "The goal is to make sure people are healthy and lead a healthy lifestyle," she says. It is important to know what preventative care costs are covered in your plan because then you can properly challenge certain bills if necessary, she says.

Know your drug benefits. If you are taking a particular drug as treatment, you need to know it is on the list of covered drugs. Also make sure you determine if there is a pre-authorization process.

In general, says Wade, become comfortable with your power as a consumer and know that there is nothing wrong with picking up the phone and asking questions.

Nedra Rhone writes for The Atlanta Journal-Constitution. E-mail: nrhone(at)ajc.com.

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