CHCR: Reading Policy Description Carefully is Key to Using Health Insurance Coverage Effectively

By Los Alamos Community Health Care Roundtable

It’s four months into the new health insurance plan year, and if provider experiences are any indication, that hasn’t been enough time for people to figure out exactly what “High Deductible” – especially as it relates to Los Alamos National Laboratory’s new insurance offerings – means.

As defined by the glossary, “Deductible” is “The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.”

The glossary further defines “High Deductible Health Plan” as “A plan that features higher deductibles than traditional insurance plans. High deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.” In most cases, an HDHP offers significantly lower premiums, with the assumption that subscribers will pay more out of pocket for services obtained prior to meeting their deductibles.

To “meet your deductible” means that you pay out of pocket for services up to the deductible amount. This year’s questions seem to arise from patients, especially LANL employees, who were not fully aware of their deductible amount or who haven’t read all the terms of their plans. It appears the lower premiums initially looked attractive, but now that costly co-insurance payments are coming due, the reality of “high deductible” is setting in.

Although a wealth of information is available for all insurance plans, patients who have signed up for an HDHP may not have fully availed themselves of such, if their confusion when presented with the entire bill for office visits early in the year is any indication. Patients also likely do not understand that providers are governed by federal regulatory standards requiring very accurate reporting of services rendered when submitting bills to either insurance plans or Medicare/Medicaid.

One example is the annual physical exam. At Blue Cross/Blue Shield (BCBS), this exam falls under the category of Preventive care/screening/immunization, a service for which the deductible may be waived. The physical, as defined by regulatory standards, entails specific assessments and preventive care, which the physician and his/her staff perform during the visit. However, if, at the exam, the patient presents a completely new problem, or discusses new symptoms that require different medical management, those items are NOT included in the routine physical and must be billed separately. In that case, the patient would likely receive a separate charge for an office visit and care related to the new medical issues.

Some patients may elect to wait on discussing their new non-acute issues until they have met their deductible. Others may feel that their problem is so pressing that they are willing to pay immediately to receive the doctor’s care during their physical exam visit. In any case, it is imperative for patients to understand their plan and the definition of terms contained therein and to discuss those terms with their provider when making decisions about their care.

The key to using health insurance coverage effectively is to read the policy description very carefully, explore terms and follow leads to such resources as the plan formulary (listing of covered drugs). Also available are websites like, which outlines services considered preventative. Consumers may and should call their health plans for answers to specific questions. Health insurance companies differ from each other, and plans offered to individuals and employers by a single company are different. Providers are not always privy to specifics of different plans, so patients are accountable for learning the specifics of their insurance choices.

For example, the HDHP for Los Alamos National Laboratory’s Active Employees or Retirees w/o Medicare Plan has an overall deductible when using preferred (in-network) providers of $1,500 per individual or $3,000 per family. These amounts are doubled when using non-preferred providers. The patient pays all costs up to this deductible amount. This is very different from the more familiar “PPO” plan where the annual deductible is much less, $300/individual or $900/family. That is why the premiums are lower for the HDHP. The patient pays more of the costs directly. 

To further complicate matters, not all out-of-pocket expenses count towards meeting the deductible. Residential treatment centers, premiums themselves, and charges that would not be covered by insurance anyway do not count.

As with the LANL PPO plan, patients in its HDHP do not need a referral to see a specialist. But if the specialist is not a preferred provider in the BCBS network, the patient may have to pay the full bill directly since the deductible is high.

The LANL examples cited above may not apply to other plans, even other BCBS plans. Each person needs to understand his or her own plan – preferably before choosing it at annual enrollment time. A well-informed patient can help manage his/her costs, but it takes effort.

Editor’s note: Los Alamos Community Health Care Roundtable (CHCR) includes providers, organization liaisons, employees, retirees, community representatives and others interested in local, statewide and national health care. An independent organization in its 17th year of existence, CHCR has found confusion over high-deductible health insurance to be common among local consumers.

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