Who doesn't like new things? New car, new computer, new puppy. New health insurance? Eh… Hi, my name is Jon, I'm your Health Care Hacker. And in today's episode, we're going to talk about what happens when you get new insurance. (music) Sometimes it's a choice, you might go through open enrollment and decide, "I want a different plan." Sometimes you don't have a choice. Maybe your plan's no longer offered. Maybe your employer's decided to switch which insurance company they go with. Then you've got some research to do so you don't get surprised or stuck with a bill that you weren't expecting. So, to start off you should ask for something called the Summary Plan Description document, or SPD for short. First off, let me warn you, it is long and boring.

But it lays out what the plan covers and what it doesn't cover, usually it's in the middle section. First off there's some common issues that I see when people are switching plans. One of those might be something like therapies. Lots of times, plans limit how many therapies you can have in a year. So let me give you an example. Let's say you've got a bad back and you go to the chiropractor every week. Your new plan may limit it to 20 visits per year. You want to know that because, end of the day, after you get your 21st visit, you're going to be financially responsible.

You should also look at the SPD if you have a specific service that you're worried about. Might be Lasik, might be infertility, it might be bariatric surgery. Look and see what the coverage is, it'll lay out whether it's covered or not by your plan. And if it is, what level it's covered at. Now, unfortunately, that document doesn't contain all the information you need to make a good decision. For example, it doesn't contain the network. Doesn't tell you if your doctor's going to be in-network or not, or if your hospital is going to be in-network or not. You're going to have to go to the plan's website to research that. Put your doctor in, give 'em your plan, to see if you're in-network for your new plan. I've seen this mistake too often, people assume well, I had the same insurer, I just have a different plan. So I'm assuming my doctor is in-network. That's not the case. You can have different networks with the same health insurance provider. So another thing that's not in the SPD is a formulary.

Which is prescription drug coverage. If there's a certain drug that you're taking, you're going to want to make sure that it's still covered in that formulary. Now there's instances where, maybe your doctor's out of network, and maybe the drug that you take isn't in the formulary. What do you do? Well first off, if it's something around continuation of care, so you just had surgery, or you have cancer, or maybe you're pregnant, you can continue to see the same doctor for a period of time. It's laid out in the Summary Plan Description document, but oftentimes, for 90 days you can see that doctor, and they'll be treated as if they're in-network. But please review your plan before you make that decision. Secondly, you can also appeal coverage. So if there is a drug that you take for a specific medical reason, oftentimes your doctor can put a medical necessity appeal in to try to get that drug added to your formulary to see if it'd be covered.

If there's a specific reason why you're taking it, there's probably a good chance it'll be covered. Let's say that's not successful, your doctor's still out of network or the drug's still not covered in the formulary. Well if your doctor's out of network and you still want to see them, they're going to be more expensive, but they may be willing to do some sort of negotiation contract with you to help lower some of those costs so you can still see them. As far as the formulary goes, you'll probably want to have a conversation with your doctor to see if there's another drug that is similar to the drug you're taking which will be part of the formulary that is covered by your new insurance plan. So, you get new insurance, your head can explode. Focus on a couple things: Is your doctor in-network? Is the drug you're taking, is that still in your formulary? And finally, if you have some services you do on a regular basis, check that SPD to make sure they're covered.

If you have a question, or there's a topic you want us to cover in the future, please email us at And we'll try to address it in a future episode..



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