I have health insurance. Now what?
October 8, 2014 8:44 AM Subscribe
Asking for a friend: Please help a complete (and mostly healthy) newbie figure out how to navigate the US healthcare system in CA. Explaining like you would to a five-year-old would be great.
So for the first time in my life, I have comprehensive health insurance (thank you Obamacare!) The thing is, coming from a country where health insurance isn't a thing, I have no idea how it works.
Snowflake details:
- I have coverage through my school-specific plan (Anthem Blue Cross in CA)
- I am 26, more or less healthy, no major problems.
- Based on a couple of observations, and conversations with friends, I may have type 2 diabetes.
My question is: how do I even start? I'm not exaggerating when I say I have no idea where to begin; do I just call a doctor that takes my insurance and set up an appointment? As for getting tested for diabetes, do I go to a primary care doctor first, so they can order tests for me, or do I find a lab and ask for tests? Help!
So for the first time in my life, I have comprehensive health insurance (thank you Obamacare!) The thing is, coming from a country where health insurance isn't a thing, I have no idea how it works.
Snowflake details:
- I have coverage through my school-specific plan (Anthem Blue Cross in CA)
- I am 26, more or less healthy, no major problems.
- Based on a couple of observations, and conversations with friends, I may have type 2 diabetes.
My question is: how do I even start? I'm not exaggerating when I say I have no idea where to begin; do I just call a doctor that takes my insurance and set up an appointment? As for getting tested for diabetes, do I go to a primary care doctor first, so they can order tests for me, or do I find a lab and ask for tests? Help!
Call your insurance company or check out their website.
Compile a list of doctors for primary care that are "accepting new patients" that you should be able to get via phone or the website.
You can also ask for recommendations from your social media network in your geographical area or by googling reviews of specific doctors, etc.
There are also several different kinds of primary care physicians. We prefer family practitioners and we primarily see nurse practitioners through the practice we go to, though we are under a specific doctor on our insurance.
Then once you've selected someone, you call their office, state you are interested in becoming a new patient and would like to make an appointment if possible.
If this is a school based health insurance, you might also be limited to seeing your school's health services for routine appointments. Depending on the size of the school, they may have a full range of options or just a couple of staff members for routine illnesses. Either way, starting with them may make the most sense depending on how your school insurance is set up.
posted by zizzle at 8:54 AM on October 8, 2014 [1 favorite]
Compile a list of doctors for primary care that are "accepting new patients" that you should be able to get via phone or the website.
You can also ask for recommendations from your social media network in your geographical area or by googling reviews of specific doctors, etc.
There are also several different kinds of primary care physicians. We prefer family practitioners and we primarily see nurse practitioners through the practice we go to, though we are under a specific doctor on our insurance.
Then once you've selected someone, you call their office, state you are interested in becoming a new patient and would like to make an appointment if possible.
If this is a school based health insurance, you might also be limited to seeing your school's health services for routine appointments. Depending on the size of the school, they may have a full range of options or just a couple of staff members for routine illnesses. Either way, starting with them may make the most sense depending on how your school insurance is set up.
posted by zizzle at 8:54 AM on October 8, 2014 [1 favorite]
Find a doctor who takes your insurance (either through your insurance company's website, or through a recommendation from a friend or colleague). Make an appointment. They'll want to see your insurance card the first time and maybe after that. There might be a copay. Bring something to do while you wait.
Talk to this doctor about your symptoms, and they will probably send you to a lab to have blood drawn. You may or may not have a copay or a bill for this. Ask this doctor when you should expect to hear about your test results.
The doctor will probably call you back with test results, or mail them to you. If you don't hear back by the date the doctor provided, call them. Be relentless. You might need a followup appointment or more blood work.
posted by chesty_a_arthur at 8:55 AM on October 8, 2014
Talk to this doctor about your symptoms, and they will probably send you to a lab to have blood drawn. You may or may not have a copay or a bill for this. Ask this doctor when you should expect to hear about your test results.
The doctor will probably call you back with test results, or mail them to you. If you don't hear back by the date the doctor provided, call them. Be relentless. You might need a followup appointment or more blood work.
posted by chesty_a_arthur at 8:55 AM on October 8, 2014
Yep, first step is to find an internist or general practitioner who takes your plan. They will do a an annual exam ("a physical") and then recommend what to do next. If they want lab tests they will give you a form and send you to a lab. If they are concerned about diabetes they may send you to an endocrinologist.
One thing to note is do you have a PPO or an HMO plan? If you have HMO, you generally have to get a referral from your GP to see a specialist. With a PPO you can go to a specialist directly. That said, it is best to have a GP to help coordinate your care.
Take a look at your plan details so that you understand what your coverage is. A couple things to understand:
- In-network: Doctors, facilities, etc that have contracts with your insurance company/plan. These are "covered."
- Out-of-network: Your insurance may or may not provide any out of network coverage. If they do, they generally cover less.
- Copay: A flat fee that you pay for some services/items such as doctor's appointments, prescriptions
- Deductible: The amount you have to pay out-of-pocket for services before insurance will start paying. You may or may not have a deductible. (Does not apply to services that are covered under a copay). Deductibles roll over every year, usually on January 1.
- Coinsurance: The percentage of that you have to pay for services. If you have 20% coinsurance and a service is $100, you have to pay $20 and your insurance pays $80.
- Out-of-pocket max: The maximum you'd have to pay yourself during the year (coinsurance, copays, deductible, etc). For example I have a $3000 OOPM. Once I've spent $3K myself this year the insurance covers everything.
Do you have dental and/or vision? These are usually a little different but more simple. They generally give you an allowance for a set dollar amount of coverage.
posted by radioamy at 8:56 AM on October 8, 2014 [1 favorite]
One thing to note is do you have a PPO or an HMO plan? If you have HMO, you generally have to get a referral from your GP to see a specialist. With a PPO you can go to a specialist directly. That said, it is best to have a GP to help coordinate your care.
Take a look at your plan details so that you understand what your coverage is. A couple things to understand:
- In-network: Doctors, facilities, etc that have contracts with your insurance company/plan. These are "covered."
- Out-of-network: Your insurance may or may not provide any out of network coverage. If they do, they generally cover less.
- Copay: A flat fee that you pay for some services/items such as doctor's appointments, prescriptions
- Deductible: The amount you have to pay out-of-pocket for services before insurance will start paying. You may or may not have a deductible. (Does not apply to services that are covered under a copay). Deductibles roll over every year, usually on January 1.
- Coinsurance: The percentage of that you have to pay for services. If you have 20% coinsurance and a service is $100, you have to pay $20 and your insurance pays $80.
- Out-of-pocket max: The maximum you'd have to pay yourself during the year (coinsurance, copays, deductible, etc). For example I have a $3000 OOPM. Once I've spent $3K myself this year the insurance covers everything.
Do you have dental and/or vision? These are usually a little different but more simple. They generally give you an allowance for a set dollar amount of coverage.
posted by radioamy at 8:56 AM on October 8, 2014 [1 favorite]
Absolutely call the insurance provider. They will help you navigate the system and explain how it all works. This includes finding doctors in your area, who meet your criteria (male/female/type of doctor/etc), and who take your insurance.
I've had Blue Cross - it was years ago, and found them incredibly helpful as a place to start.
Another option is to start calling doctors to see if they take Anthem Blue Cross, or to check the Blue Cross website for a directory of health care providers. But you want simple, so start with the number on the insurance card.
A diabetes test will be through a primary care doctor. Is this friend from Canada? As someone who lived in California most of my life and then moved to Canada, I had the reverse issue. Figuring out how to navigate the health care system here. There are some definite differences between US-insurance and Canada Healthcare that threw me for a loop. I could see it happening the other way around as well.
posted by routergirl at 9:07 AM on October 8, 2014
I've had Blue Cross - it was years ago, and found them incredibly helpful as a place to start.
Another option is to start calling doctors to see if they take Anthem Blue Cross, or to check the Blue Cross website for a directory of health care providers. But you want simple, so start with the number on the insurance card.
A diabetes test will be through a primary care doctor. Is this friend from Canada? As someone who lived in California most of my life and then moved to Canada, I had the reverse issue. Figuring out how to navigate the health care system here. There are some definite differences between US-insurance and Canada Healthcare that threw me for a loop. I could see it happening the other way around as well.
posted by routergirl at 9:07 AM on October 8, 2014
If your university has a student health center thst would be the best place to start. While their expertise is generally dispensing birth control pills and adderall, it should be easy for you to go. And if your insurance is through the school, they will take it. Go to their website and set up an initial appointment with a primary care person.
posted by k8t at 9:07 AM on October 8, 2014
posted by k8t at 9:07 AM on October 8, 2014
Regarding k8t's suggestion, I'd check with your fellow students about the student health center's reputation. My school's health center was horrible and you only went there as a last resort. Some schools are probably fabulous. YMMV.
posted by radioamy at 9:14 AM on October 8, 2014
posted by radioamy at 9:14 AM on October 8, 2014
Response by poster: Quick note: My friend's school is tiny, and private, and does not have a health centre, just an on-call nurse, hence my question.
posted by Tamanna at 9:23 AM on October 8, 2014
posted by Tamanna at 9:23 AM on October 8, 2014
Find a GP through your insurance and schedule an annual physical. This is 100% covered under all health plans. At the physical the doctor will run blood tests, discuss your general health and do a full assessment. You may have to pay a co-pay for the lab work, so be sure to discuss which labs are covered under your insurance, and ask which labs your doc uses.
Then if there are any medications prescribed, take them to the pharmacy covered under your plan and get them filled.
Also, your friends can't tell you you have type 2 diabetes. That's silly. But DO go see a doctor. Annually!
posted by Ruthless Bunny at 9:27 AM on October 8, 2014
Then if there are any medications prescribed, take them to the pharmacy covered under your plan and get them filled.
Also, your friends can't tell you you have type 2 diabetes. That's silly. But DO go see a doctor. Annually!
posted by Ruthless Bunny at 9:27 AM on October 8, 2014
Oh! If meds are prescribed, make sure they're the cheapest ones on your Formulary.
Either link to that on your phone, or print it out and take it with you. That will save you ALL kinds of money!
posted by Ruthless Bunny at 9:30 AM on October 8, 2014
Either link to that on your phone, or print it out and take it with you. That will save you ALL kinds of money!
posted by Ruthless Bunny at 9:30 AM on October 8, 2014
The only time I use the insurance companies list of doctors, I had a hard time finding one that could make a timely appointment or was taking new appointments. Ask friends for references and call the doctor first. There are a lot of doctors out there that will take your insurance that aren't on the list or in the provider book.
posted by iscavenger at 10:03 AM on October 8, 2014
posted by iscavenger at 10:03 AM on October 8, 2014
In addition to all of the above, if you're a woman, when you make the physical appointment ask if they also do well woman exams - you don't have to make a special trip to a gynecologist for a PAP smear if they do them. Also, ask about the need for vaccinations: TDAP (tetanus, diphtheria, pertussis) if it's been 10 years since your last one and a flu shot.
posted by cecic at 11:02 AM on October 8, 2014 [1 favorite]
posted by cecic at 11:02 AM on October 8, 2014 [1 favorite]
You need to have one main doctor to oversee all your care. This doctor will send you to specialists if need be. This main doctor will usually have a physician's assistant who can handle almost everything and when you call your doctor to make an appointment ask the receptionist if the PA can handle your problem. Because it will be cheaper. You should in fact try to get a main doctor who has a PA. It would be totally appropriate to make an appointment first with the PA to get your blood work done and then make an appointment with the doctor to discuss the results. You absolutely need to get blood work done right now. The sooner you know you are OK the less stress you will have and if you have a problem you need to treat it right away. You may need to fast overnight (no breakfast) before the test. But remember to drink water or it will be hard to draw blood. Ask the receptionist what to do before the test. They may assume you already know. And you don't want to waste an appointment by eating first.
Some abbreviations you need to know:
PA - Physician's Assistant
GP - General Practitioner (I think this is the same as what they used to call a "family doctor", anyway, they generalize and would be good for your "main" doctor)
PCP - Primary Care Physician (this is what you would call your main doctor)
posted by cda at 11:44 AM on October 8, 2014
Some abbreviations you need to know:
PA - Physician's Assistant
GP - General Practitioner (I think this is the same as what they used to call a "family doctor", anyway, they generalize and would be good for your "main" doctor)
PCP - Primary Care Physician (this is what you would call your main doctor)
posted by cda at 11:44 AM on October 8, 2014
You might find this PDF guide by the federal government helpful.
posted by ThePinkSuperhero at 4:16 PM on October 8, 2014
posted by ThePinkSuperhero at 4:16 PM on October 8, 2014
If you're having some kind of symptoms (and I assume you must be if you think you have diabetes), one tactic you can try is that if you're finding it impossible to schedule an appointment with a doctor in a timely manner, and they're all telling you that the nearest 'new patient' appointment is 2 or 3 months away, you could try asking if you can schedule an urgent visit and a new patient visit at the same time, because you have a problem that you really need help with right now and you'd be happy to follow up to run through all the rest of your preventative healthcare needs and background information at a future date if you can get a quick appointment to discuss this problem now.
There are certainly younger and younger people being diagnosed with type 2 diabetes these days, but if it's any reassurance, if you truly are 26 years old and "healthy", then type 2 diabetes is not likely (ref 1, ref 2). You can pick up urine test strips on Amazon that will test your urine for glucose, which is not the way diabetes is formally diagnosed, but would give you a quick and dirty method to provide evidence for or against your hypothesis. Obviously, you still need to see a doctor either way.
posted by treehorn+bunny at 9:00 PM on October 9, 2014
There are certainly younger and younger people being diagnosed with type 2 diabetes these days, but if it's any reassurance, if you truly are 26 years old and "healthy", then type 2 diabetes is not likely (ref 1, ref 2). You can pick up urine test strips on Amazon that will test your urine for glucose, which is not the way diabetes is formally diagnosed, but would give you a quick and dirty method to provide evidence for or against your hypothesis. Obviously, you still need to see a doctor either way.
posted by treehorn+bunny at 9:00 PM on October 9, 2014
re: There are a lot of doctors out there that will take your insurance that aren't on the list or in the provider book.
Be careful about this. A doctor may "take your insurance" but he may not be "in network". Most insurance companies have a chart that tells how much they pay vs how much you pay, and if you choose "out of network" then you pay more.
posted by CathyG at 12:50 PM on October 10, 2014
Be careful about this. A doctor may "take your insurance" but he may not be "in network". Most insurance companies have a chart that tells how much they pay vs how much you pay, and if you choose "out of network" then you pay more.
posted by CathyG at 12:50 PM on October 10, 2014
This thread is closed to new comments.
posted by woodvine at 8:52 AM on October 8, 2014