I never thought I would be sick. Like so many other people, I figured for most of  my life I would hardly use my health insuranc; complaining about it occasionally at family gatherings but accepting it as one of those annoying but necessary costs of doing business. On May 1, 2009 the day I qualified for health insurance nothing remarkable happened, my parents were probably more happy about the news than me. So for almost two months the little plastic card sat comfortably in my wallet, maybe received one or two glance overs to verify co-payment and deductible rates.I noticed fine print regarding in-network versus out-of network coverage, figured enough that it would be my benefit to stay in-network, it just sounded more inviting. The concept of co-insurance, wasn’t a concept I knew existed. Prior to my diagnosis of aplastic anemia, I assumed the insured(me) was responsible for a co-payment with any doctor’s consult, and if treatment for something serious was necessary, I would pony up and pay until my deductible was paid and that was it. My partner, Blue Cross Blue Shield, would take care of the rest. I was wrong. All policies are different, but ones like mine are far from an exception—most who are not in a union and do not work for a large corporation have something similar.

An example, If I consult an in-network cardiologist, meaning he has a contract with my insurer, for a routine examination, I pay $50 for the visit, that’s the co-payment. Suppose he sends me for a expensive test or two, the co-insurance agreement then kicks in, meaning the amount shared by me and my insurer to undergo anything that isn’t—-straight from my Member Benefits Manual—-”office visits, examinations, evaluations, and consultations.” So they mean all diagnostic studies and  tests, a.k.a the expensive stuff, you share the cost. Come on, it’s a partnership. The cardiologist was in-network doctor so the bill is divided, I pay 20% of the total cost, my insurer pays 80%. If I went to an out-of-network doctor the agreement changes, I pay 40%, my insurance pays 60%.  If those tests are a$10,000 or $20,000 workup, you understand why staying in-network is crucial. It’s important to note there is a point where you max out the amount you have to spend in a year, called the maximum out of pocket expense, consistent with the plan the in-network max out will be substantially lower than out-of-network max.

Hopefully reform in Washington will work to ensure this is a much more tangible, transparent process for insured. For now, dust off the Benefits Manual, open it up and take a look at what you’re working with, worse case scenario is you’re a more empowered patient than you used to be.

Here is a solid glossary of basic health insurance terms.

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