WHAT IS THE INSURANCE AND FINANCIAL SITUATION?

Once you've considered the urgency of treatment need, it's helpful to examine some insurance and financial questions.

Do you have health insurance?

Uninsured individuals have less options when it comes to medical care, or they face the possibility of massive medical bills and debt. If you are uninsured, it's probably a good idea to look into purchasing coverage or finding out if you qualify for Medicaid. If coverage is still not an option, you may want to find federally qualified health centers (FQHC's) and other safety-net facilities in your community should you have an emergency or an unforeseen need for expensive medical care. Nearby urgent care and retail centers can also be a good resource for the uninsured because they tend to have fairly affordable self-pay prices for basic medical services.

For those who do have health insurance, your medical care options are generally only limited by your plan's participating network of physicians. Any physician, practice, or hospital that is in-network with your plan can be utilized. Some plans require a PCP visit and referral in order to visit a specialist, but this is becoming more and more rare. Beyond that it comes down to finding the right provider for you in terms of quality, service, and affordability.

What are your health insurance plan benefits?

Here is a quick list of things that everybody should know about their health insurance plan. You can normally obtain this information from your insurance carrier, your broker, and/or your employer if they provide your coverage.

• What carrier are you with? Your options may be slightly different if you have Medicare or Medicaid as opposed to private insurance like United healthcare, Anthem Blue Cross & Blue Shield, Aetna, Cigna, Humana, or Kaiser Permanente.
• What type of plan are you on? Common plan types include PPO, POS, and HMO. Perhaps the most significant thing you'll want to familiarize yourself with is your plan's network of providers. Can you see any physician that is contracted with the carrier (as in many PPO and POS plans), is the network limited (as in some HMO and EPO plans), and are out-of-pocket costs higher if you receive out-of-network care (which is usually the case).
• What are your specific plan benefits? In particular, it's important to understand your out-of-pocket cost obligations, so make sure you understand your copay, coinsurance, deductible, and out-of-pocket maximum terms and how they apply in all care settings (e.g. inpatient hospital vs outpatient).

What is your ability to pay out-of-pocket cost obligations?

This will affect how cost-sensitive you are and how much emphasis you should put on choosing the most affordable care option. If money is no object, and even your out-of-pocket maximum figure doesn't concern you, then you can seek whatever care you'd like regardless of the cost. However, if you're like most of us that need to budget our expenses and practice frugality, it's probably smart to consider how financially prepared you are for both routine medical costs as well as (knock on wood!) catastrophic medical events. This is when saving money by making informed choices starts to make a whole lot of sense!

Essential QSA Knowledge

We assume that just about everybody knows if they have health insurance or not, but understanding the implications of being uninsured is important. Ultimately uninsured patients are responsible for all of their medical expenses, and it places a burden on the entire healthcare system when uninsured patients are unable to pay for services. Everybody should be aware of their health insurance benefits especially their potential out-of-pocket cost obligations. Finally, it's good to be consciously aware of your financial position and your ability to absorb medical costs. This will help shed light on why it's important to shop around and make informed medical care decisions.

For the next patient choice consideration, visit What provider option achieves QSA Optimization?

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