The new year is a time for fresh starts, and for many people, that means setting health goals. Whether it’s scheduling annual check-ups, managing chronic conditions, or finding a new primary care provider, one of the most overlooked yet crucial steps to achieving these goals is understanding your health insurance. Navigating your insurance coverage can mean the difference between easily accessing the care you need or facing unexpected costs and roadblocks.
To help break down the complexities of health insurance, we’ve gathered insights from family physician Dr. LaTasha Seliby Perkins. Here’s why reviewing your health coverage is a vital first step toward a healthier 2025—and how you can ensure your insurance supports your wellness goals.
Avoid Unexpected Costs by Understanding In-Network vs. Out-of-Network Providers
One of the biggest misconceptions about health insurance is that you can’t see an out-of-network provider. According to Dr. Perkins, you can—but it will come at an added cost. Understanding whether your provider is in-network or out-of-network is crucial to avoiding surprise expenses.
Here’s what you need to know:
- In-network providers have agreements with your insurance company, meaning their services are covered at a higher percentage.
- Out-of-network providers may still be covered, but your insurance will likely pay less, and you may have to submit the paperwork yourself for reimbursement.
The best way to avoid unexpected costs is to check your insurance plan before making appointments. If you need to see an out-of-network provider, make sure you understand what portion of the cost you’ll be responsible for.
Key Health Insurance Terms to Know
For those unfamiliar with insurance terminology, these key terms can help you make informed decisions:
- HMO vs. PPO: An HMO (Health Maintenance Organization) requires you to stay within a specific network of providers, while a PPO (Preferred Provider Organization) allows you to see specialists without referrals and offers more flexibility in choosing providers.
- Copayment: A set fee you pay out-of-pocket for each visit or service, separate from what your insurance covers.
- Deductible: The amount you must pay before your insurance begins to cover costs. For example, if you have a $2,000 deductible, you’ll need to pay that amount before insurance starts covering a percentage of expenses.
Understanding these terms can prevent confusion and help you select a plan that best meets your needs.
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Maximizing Preventive Care Benefits
One of the easiest ways to take advantage of your insurance is by scheduling preventive care visits. Most insurance plans cover an annual physical, which includes lab work and screenings at no extra cost to you.
Dr. Perkins recommends:
- Scheduling an annual check-up with your primary care provider.
- Women should consider seeing both their primary care provider and OB-GYN for comprehensive care.
- Using your preventive care visit to discuss wellness goals and plan additional appointments for the year.
By utilizing these benefits, you can catch potential health concerns early and avoid costly medical issues down the line.
Choosing the Right Insurance Plan During Open Enrollment
If you’re considering switching insurance plans, Dr. Perkins emphasizes doing your research just as you would for any major purchase.
Factors to prioritize:
- Coverage for preventive and behavioral health services (such as therapy).
- Access to specialists and complementary treatments like acupuncture or massage.
- Whether all your current doctors are in-network.
If you’re unsure about your options, call your insurance provider and ask questions. The earlier you gather information, the better prepared you’ll be when making a decision.
Managing Chronic Conditions with the Right Coverage
For those with chronic health issues, having all doctors within the same network can make managing care easier and more affordable.
Dr. Perkins advises:
- Choosing an HMO plan if you want all your doctors in one system, ensuring better communication between providers.
- Maintaining a primary care provider (PCP) and a “medical home” to help coordinate care and reduce costs.
Having a strong relationship with a PCP allows for better management of conditions like diabetes, high blood pressure, and heart disease, ultimately reducing hospital visits and unexpected medical expenses.
Balancing Cost Concerns with Quality Care
Healthcare is an investment in your well-being. Dr. Perkins reminds patients to view health insurance as a necessity rather than a luxury:
“People don’t hesitate to pay rent, car payments, or buy clothes, but they sometimes undervalue healthcare. If your health deteriorates, nothing else matters,” Dr. Perkins notes.
To balance cost and care:
- Make sure your plan provides adequate coverage for the services you need.
- Utilize financial assistance programs or health savings accounts (HSAs) if available.
- Work with your provider’s office staff—they often have insights into cost-saving options.
Improving Health Literacy for Better Decision-Making
Many people struggle with health literacy, which can lead to misunderstandings about their coverage and medical care. Dr. Perkins suggests:
- Asking your doctor to explain things in plain language rather than medical jargon.
- Seeking out patient advocates or insurance navigators to help clarify policies.
- Researching reputable sources, like FamilyDoctor.org, rather than relying solely on social media for medical advice.
If something is unclear, don’t hesitate to ask questions—your health is too important to leave to guesswork.
Proactively Managing Your Health in 2025
A key trend Dr. Perkins sees is people turning to social media for health information. While some providers share useful content online, she encourages patients to verify information with their doctor before acting on it.
She also stresses the importance of having a primary care provider to ensure continuity of care. Without a PCP, coordinating care can be difficult, and patients may struggle to access necessary treatments.
Final Thoughts
Navigating health insurance may seem overwhelming, but taking the time to understand your coverage is a critical step in maintaining good health throughout the year. By ensuring your plan aligns with your health goals, maximizing preventive care, and making informed choices about providers, you can start 2025 on the right foot—feeling confident in both your health and your financial well-being.
If you’re unsure where to start, check your insurance plan details, reach out to your provider, and schedule that all-important annual physical. Your future self will thank you.
