In this episode of Disruptive Dialogue, Chuck continues hisHealthcare 101 series on private insurance. Healthcare literacy matters in our complicated system, and learning the basics makes all of us better consumers. Listen in!
After recapping the basics of premiums, deductibles, and copays from the last episode, he dives into the barriers that keep patients from accessing the care they need—and how to overcome them. This episode equips you with practical knowledge and strategies to advocate for yourself and your family.
Learn About
Common barriers to accessing care with private insurance
How/why insurers use administrative tools like prior authorization and step therapy
Ways patients can appeal denials and delays
Strategies to prepare during enrollment to avoid costly surprises
The pros and cons of private insurance from the patient’s perspective
Key Terms & Definitions
Premium: The fixed monthly payment you make for insurance coverage, whether or not you use services.
Deductible: The amount you pay out of pocket before insurance begins to cover costs.
Copay/Coinsurance: Your share of the cost for services or prescriptions after meeting your deductible.
Prior Authorization: Requirement for insurer approval before certain tests, drugs, or procedures are covered.
Step Therapy (Fail-First Policy): Policy requiring patients to try lower-cost drugs or treatments before moving to more expensive options.
High Cost Sharing: Large deductibles, copays, or coinsurance amounts that make care unaffordable.
Copay Accumulator / Maximizer: Insurer policies that absorb drug manufacturer copay assistance, leaving patients with higher costs once assistance runs out.
Non-Medical Switching: When insurers force patients to change medications for cost reasons rather than medical ones.
Formulary: A list of prescription drugs covered by an insurance plan, often with restrictions.
Quantity Limits: Restrictions on how much medication can be dispensed at one time.
The Takeaway
Private insurance can provide choice and financial protection, but navigating its barriers requires preparation, persistence, and advocacy. Be prepared!
Season 2 of Disruptive Dialogue will give you the tools you need, so subscribe today, and share with your friends and family before open enrollment season starts.
Stay Connected!
Visit https://www.disruptivedialogue.org/get-involvedfor episode slides and more resources.
Have questions or feedback? Reach out through the contact page.
Subscribe to our newsletter for weekly updates right to your inbox.
If you found this episode helpful, share it with a friend or colleague who could benefit.
Subscribe to Disruptive Dialogue with Chuck Melendi so you don’t miss the next episode in the Healthcare 101 series.
