A terrible guide to the terrible terminology of U.S. Health Insurance

hello I'm Brian David Gilbert and  recently my Cobra Insurance ran out so I  used that qle to look up some hdhps and  ppos but ended up going with an average  premium HMO health insurance policy  every word in that sentence burned as it  came out of my mouth that's right folks  I'm talking about the beautiful American  tradition of Private health care  something embedded so deeply in the  heart of the American people that only a  surgeon could excise it and it would  cost at least sixty thousand dollars as  an adult who left a job with benefits at  the end of 2020 I had planned to find my  own health insurance much earlier but I  had doctors and therapists that I  already liked and every time I faced the  marketplace's heinous user interface and  jargon-filled summaries my mind would  shrivel up like a deflating parade  balloon  so when I was forced to find a new  health insurance provider in June of  this year I decided to learn everything  there was to know about the fsas and the  hsas and the chips and the dips and one  two three  oh there that's jazz baby I do finally  have new health insurance although it  was a long and difficult road to get  there and although I am definitely not  the best person to explain the  intricacies of the marketplace I've made  this video to help ease you into the  terminology in case you need to purchase  health insurance and don't want to spend  a year and a half doing what I did  sure this video is a little different  from the ones that I've made in the past  but I am nothing if not unpredictable  I'm don't put that in the screen I'm  unpre I'm unpredictable and for those of  you non-americans watching this video  and thinking I do not need to watch this  video I am British consider this a  cautionary tale because there are  definitely people in your country that  want to privatize Healthcare and you  can't let them do that  can't let them do that so let's get into  it please enjoy this cursory and most  likely useless guide to American Health  Insurance terminology  that's health insurance look we got to  start with a strong Foundation insurance  is a way to manage risk say I've got a  figurine that I really love and would be  heartbroken if something ever happened  to it an insurance company could  quantify that emotional attachment and  say hey if somebody happens to your  figurine we'll pay you a hundred dollars  all you gotta do is pay us one dollar  every month so if I sign that contract  and pay them one dollar every month and  thus happen to it they'll pay me a  hundred dollars so I can replace it but  I could never really replace it  health insurance is like that but for  your health and considering your health  is defined as the mental and physical  condition of your body then health  insurance should pay for you to get  better in the event of an illness or  bone break or something  you know let's go ahead and get rid of  the mental part of that  can you make it specific parts of the  yeah  thrown extremely on top of let's settle  a vision insurance here in the United  States of America scientists have  researched for dozens of years in order  to prove one inimitable truth your teeth  and your eyes are not a part of your  body and although we have gotten closer  to understanding what those little wet  balls are doing inside your skull nine  out of ten dentists agree that your  teeth should not be trusted  I'm a little Scamp technically these are  separate because Dentistry and Medicine  are considered different fields and so  insurance companies view them  differently and vision insurance is  different because it mostly covers eye  exams and corrective lenses like glasses  and contacts and some people don't need  them and for those that do but can't  afford it they can just squint really  hard works for me  I'm looking at the camera I'm not okay  but I'm in the right area what's a  premium oh a fancy word except it  actually just means the fee you pay your  provider usually monthly in order to  keep up your health insurance it's  essentially the same thing as a  subscription fee to Netflix except in  this case you lose your health insurance  if you stop paying it as opposed to  losing the ability to re-watch the 2015  Richie Rich reboot and both of those  things are equally tragic but the good  news is that if you pay your premium  every month you've got health insurance  and once you've got health insurance you  are set you never have to worry about  paying for Health Care ever again  that's not the case  so you pay your premium every month  that's great it allows you to carry  around a little card that says you're  insured and you can go to the doctor and  they'll give you a bill and you have to  pay all of it until you filled up your  deductible for the sake of this example  let's say that your health insurance  doesn't have co-pays or co-insurance  just because I'm getting to that and the  circular nature of health insurance  terminology makes it very difficult to  decide which to talk about first  let's say your deductible is 100 if you  go get a medical test that costs 100 you  will have to pay one hundred dollars but  after that you've fully paid up your  deductible and that means the next time  you go get a 100 medical test your  insurance will pay for it or part of it  because there's also co-pays and  coinsurance but again I'm getting there  your deductible resets with your plan  and most plans work on the calendar year  meaning your deductible would reset on  January 1st but if your plan is through  your work and renews in the middle of  the year it might be a different date  your premium and your deductible are  often inversely related so if you pay  very little in premium your deductible  will be way higher but if you pay a lot  every month your deductible will be  small and this brings me to my favorite  part of health insurance which is  hello welcome back everyone welcome back  we got ourselves a young healthy man  here looking to get himself some health  insurance so let me ask you something Mr  Gilbert do you think you're going to  break your leg this year uh no I I  wasn't planning on it oh it sounds like  you're gonna go with a low premium High  deductible plan that will save you money  okay yeah I don't know what that means  but I'm excited okay  oh no it looks like we should have fixed  those steps a little earlier today  because you broke your leg anyway seems  like you'll be paying that high  deductible at high speed  hahaha  there are some health insurance plans  that are literally called catastrophic  health plans for this very reason you  usually have to be under 30 in order to  get one and although you pay very little  in your monthly premium the plan doesn't  cover anything outside of three primary  care visits a year so sure you save a  lot of money on that monthly premium but  you better hope you don't get in an  accident or else it's gonna be a  catastrophe for real though it is better  than nothing this Health Plan might not  get you a lot of preventive care but it  could kick in during a catastrophic  accident and keep you from going  bankrupt or you might go you might go a  little bankrupt but you won't you won't  go like super saiyan bankrupt but on the  other hand you can also get no  deductible health insurance which has  way higher premiums but it allows you to  skip ahead to the good part of health  insurance where you get to pay  some coinsurance oh is it happening now  I thought I was on break you guys got to  give me more of a heads up  congratulations you finally paid your  deductible for the this year or maybe  not congrats because it probably means  you had a lot of unexpected health  issues this year so  um  what a shame but hey at least that means  you're done paying for health care this  year right  Oh no you're not co-payments or co-pays  are a set amount of money that you have  to pay whenever you receive certain  medical procedures prescription meds  tests Etc that test that cost you 100 it  might have a thirty dollar copay on it  so if you have no deductible or you've  filled up your deductible you'll still  have to pay that thirty dollars and just  to clarify you can and probably will pay  co-pays and coinsurance before you fill  up your deductible say you're getting a  standard annual checkup that might have  a 10 copay associated with it so even if  you haven't filled your deductible you  would just be paying ten dollars so  that's kind of nice and coinsurance more  like coinsurance gonna be in your pocket  anymore because you're going to be  paying with it I thought that was going  to be cleaning coinsurance is just  another way of splitting the cost with  your insurer and it's better for you if  the percentage is lower a 100 test with  a twenty percent coinsurance means  you'll be paying 20 occasionally you'll  see some things listed as a hundred  percent coinsurance which is a dirty  trick that means you'll be paying 100  percent of the costs that's not  coinsurance that's no insurance but hey  how come I still have to pay things  after I finish my deductible and  it pays before  multiple is filled does that count  toward my deductible and whatever  happened to my body oh  co-pays do not count toward your  deductible but both your copay and your  deductible count towards something else  called your out-of-pocket maximum which  is the maximum amount you would ever  have to pay for health coverage during  the year  kind of because if you go to an out of  network provider that payment won't  count toward your out-of-pocket maximum  so let's say you have an 100 monthly  premium you paid a hundred dollars for  an in-network test that doesn't have a  copay you paid fifty dollars for a copay  and coinsurance for an in-network  procedure and you paid a thousand  dollars to an out of network doctor for  a big old smooch in most insurance plans  the in-network test would count towards  both the copay and coinsurance would  only count toward your out-of-pocket Max  and the premium and the out of network  smooch would count towards neither but  it was worth it  I'm broke now back to co-pays every test  or procedure will have a different  co-pay or co-insurance associated with  it so it's definitely a good idea to pay  attention to this if you know that  you're going to need regular doctor's  visits for certain illnesses or  prescription medications which brings me  to what are drug tests yeah I mean like  ever since dinky Smokies did in  regionals penicillin kind of got nerfed  so I'm gonna put that down in tier one  um but we got levofloxacin next oh okay  that goes in the specialty here  prescription drugs are separated into  tears that correspond with their costs  though it differs from plan to plan  usually it goes generic drugs on tier  one brand name drugs on tier two fancier  or non-preferred brand name drugs on  tier three and once you hit tier 4 you  get specialty drugs which are often very  expensive and specific in what they  treat and they all have brand names like  zyvox and truxima and ozer dicks which  are coincidentally the names of my three  favorite sleep paralysis demons well hey  guys  oh the thing is some insurances have  five tiers and some have four and some  have four but skip the third if you want  to figure out if a certain drug is a  certain tier you're gonna need to check  with your provider's drug formulary  which is a list of every single drug  covered by your plan when you go looking  for this you'll most likely find a web  page that has dozens of links for each  specific insurance plan that will bring  you to PDFs that are a hundred pages  long and have different strengths for  different tiers and but it's still very  helpful because hey you might get  prescribed Clarithromycin for your  pneumonia and this PDF will tell you  that it is definitely a tier 2 drug or  maybe a tier three oh [ __ ] it might be  four again these drug formularies vary  wildly between providers so if you know  that you need a specific prescription  drug it's probably a good idea to check  these before signing up for a plan but  hey if you mess up don't worry because  you can always change your plan at any  time  so long as you undergo an extremely  large and potentially traumatic life  change  open enrollment is technically the only  time of the year that everyone is  allowed to change their health insurance  it usually starts on November 1st and  goes until January 15th although of  course it varies from state to state  they chose this time of the year because  no one tends to be busy prepping for any  large family gatherings or holidays it's  the most wonderful time to look at the  minutia of health insurance contracts  and compare them to different providers  because you want to make sure that you  get the best one before you get because  you're going to be locked into it for a  year or so if you missed that open  enrollment window you're stuck with  whatever health insurance you currently  have for the rest of the year except I  managed to swap my health insurance in  the middle of the year is that because  I'm special and extremely handsome no  though I am both of those things I had a  qualifying life event or qle which is  that my Cobra Insurance ran out okay hey  little sidebar Cobra stands for the  Consolidated Omnibus budget  reconciliation act but all you need to  know is that it allows you to continue  you your work-sponsored health insurance  for up to a year and a half in the event  that you leave or lose your job and it's  got a super cool name but it's hella  expensive and I'm a big dumb dummy for  continuing mine for the full year and a  half and you can all dunk on me now hey  look at this jabroni uh caping is Cobra  health insurance for a year and a half  as could have done cheaper so that's all  I can think of there are all kinds of  qles like losing a job having a family  member die or leaving prison all things  that drastically change your needs for  health insurance the thing is qles by  definition are huge life events that are  probably going to be taking up a lot of  your mental space it might be hard to do  new research on a different Health Plan  when you're busy I don't know having a  baby the bonus challenge of qles is that  they're a little like quick time events  and that you need to act quickly in  order to actually change your health  insurance  spirit  s  oh  [Music]  was that a baby this is called a special  enrollment period and it's usually 60  days before or after the qle depending  on what it is I knew my Cobra was  running out so I had 60 days before but  if it's a family member dying it'll be  60 days after because if you start  looking for new health insurance before  that's hella suspicious but it's also  important to use these qles when you  have them especially for things like  moving to a new zip code which might not  seem like that big of a deal but it is  because of what's in network versus out  of that word most insurances have a list  of providers that are considered in  network which just means that they work  with the insurance company and the  procedures you get with them will be  covered at least in part anyone who  isn't in network is surprised out of  network and doesn't get coverage now if  this seems simple that's because it is  one of the easiest things to grasp about  health insurance or it was until I  learned about multi-tiered networks this  splits your in-network providers into  different tiers with different co-pays  and co-insurances technically they are  all still in network but now some are  preferred and others aren't which makes  this diagram a little bit more blurry  apparently these plans are becoming more  popular because of course the one clear  thing about health insurance needed to  be worse the problem is that you have to  be proactive in making sure that your  doctors are in network and sometimes  moving to a new place will mean that  your insurance doesn't have anyone in  network around you this can be  especially Troublesome in emergency  situations where your first thought is  rarely I hope that they're bringing me  to an in-network provider because you're  usually thinking oh forget him on fire  according to a 2021 analysis half of all  emergency ambulance rides are out of  network meaning that even if you have an  HML plan you'll be paying for all of  that ambulance fee and none of it will  count toward your out-of-pocket maximum  hey  and even if that ambulance ride is in  network and brings you to an in-network  hospital that hospital might have some  out-of-network doctors like  anesthesiologists or sometimes an ER  doctor is a contractor and is out of  network and again it's on you to make  sure that you are being treated by  someone okayed by your insurance which  can be difficult if you're in shock or  unconscious or bleeding profusely but  that's why a lot of people on HMO plans  will wake up to a bright new day and a  big old Bill hey what is that  hey could you hey what is an HMO plan I  am getting there okay hold your horses I  have to explain the basics before I get  to the weird acronyms all right  be patient  jeez  lost my place  I'm gonna explain hmos now  EPL and POS plans so  you've got a basic understanding of the  things that make up a health insurance  plan and you're ready to dive into the  dark depths of acronym hell these are  all different types of health insurance  policies and they stand for health  maintenance organization preferred  provider organization exclusive provider  organization and point of service that  should help clear it up  let's start with an HMO plan because  that's the one that I have it's the most  common individual Marketplace plan and  its benefits are that you have a  slightly lower premium but the negatives  are that you have to stay in network and  that group of in-network providers might  be pretty small also if you need to go  to a specialist you have to be referred  by your primary care physician so if I  gotta go to a special doctor for my  special illness I first have to go  through my boring doctor  you don't have to say it like that A PPO  is much more common for employer-based  health insurance meaning that your job  will help pay for it as one of the  benefits as such the premiums tend to be  higher but you get a lot more  flexibility the network of providers is  usually bigger and you can go out of  network although it'll still be more  expensive but hey you don't need any  referrals to go see a specialist but I  would refer you if you asked me an EPO  is pretty similar to an HMO in that you  have a small network of providers and  you can't go out of network but you  don't need to have your own primary care  physician to refer you to Specialists so  this one's mostly good if you hate your  boring doctor  and the POS is kind of a combo of a PPO  and an HMO you need to have a primary  care physician but you can go out of  network if your primary care physician  refers you to them what no joke about me  this time nope  just makes me feel bad in a different  way these acronyms might seem to blend  together in certain ways and they  definitely do but don't worry I have a  totally different set of acronyms to  help add to the confusion what do HSA  MSA FSA and HRA mean oh boy let's split  these acronyms up so that way you can  tell if you even need to worry about  them in the first place a health savings  account and a medical savings account  are only available to you if you have an  HD HP which is a high deductible Health  Plan and a flexible spending account and  a health reimbursement Arrangement is  only available to you via an employer so  if you don't have an hdhp you don't got  to worry about these two and if you  don't have a job that has health  benefits you don't need to worry about  these two and if you have neither of  those things you're just like me which  isn't necessarily a good thing but it's  too late now  I'm going to be real with you this is  the part of the video I Feel the least  comfortable talking about because it  combines the two Titans of of American  bureaucracy Healthcare and taxes and the  main reason you would want any of these  acronyms is for tax benefits but it  varies based on your employer or the  bank that you're getting the account  from and I am so worried that I'm gonna  screw it up and get put on an IRS watch  list which is the worst list to be on  so I'll just give you a quick rundown  while also reminding you to do your own  research before signing up for any of  these accounts and the HSA is a savings  account for your health and so that  means you can contribute a certain  amount of tax deductible money to it  each year and then you can use that  money for any qualifying medical  expenses this money rolls over year  after year fsas allow you to contribute  a certain amount of tax-free money which  you can then use for medical expenses  that year but it's only that year unlike  an HSA this money does not roll over and  if you leave your employer you can't  take it with you but if you have a nice  employer they can sometimes offer you a  grace period of up to two and a half  months to keep using that money or they  can let you roll over some of it into  the next year but they can only choose  one of these two options but let's say  you have a thousand dollars of unused  FSA money at the end of the year and no  medical procedures to use them on you  can actually use some of that money on  over-the-counter FSA eligible items like  laxatives you just have to keep the  receipts and make sure they're approved  weirdly the best place I've found to get  information on this is not a government  website but the CVS web page because  they want your money but hey it's good  to know in case you need to quickly drop  500 on stool softener we've all been  there don't ask questions an HRA allows  your employer to reimburse you for some  medical bills and those reimbursements  are tax-free and an MSA is similar to an  HSA except with an MSA you are allowed  to never pay taxes IRS you screwed up  bucko I'm sorry okay but an MSA really  is similar to an HSA it's just that I  don't think most of you viewers are even  going to have the opportunity to get one  of these because not only do you need an  HD HP but you also have to be in  Medicare  I haven't explained what Medicare is  what are Medicare and Medicaid these two  words mean very different things but  they're both government-funded programs  related to health care so a lot of  people myself included will use one word  when they mean the other Heck if you  Google either of them the top result is  going to be Medicaid versus Medicare the  lesser-known sequel to Alien vs Predator  one of the main differences between the  two is your eligibility for Medicaid  your eligibility is based on your  modified adjusted gross income or Maggie  Magi let's go with Maggie this means  it's predominantly for low-income  individuals and families it's a federal  program but it's administered by each  state which means that each state will  have its own rules and benefits there  are some mandatory benefits but the  optional ones tend to be on the chopping  block if you live in a state that  doesn't really care about public  spending Medicare is purely Federal and  it's predominantly for people over the  age of 65. the thing is there are four  different parts of Medicare part A is  the kind where you don't have to pay a  monthly premium and it'll help with  services like inpatient stuff and  hospice care and that's wonderful but  most people aren't checking in the  hospice care because they have a minor  cold  that's it for me folks let's wrap it up  put me in the ground Medicare Part B is  what most people would think of as just  health insurance because that's  essentially what it is you have to pay a  monthly premium and you can go to a  doctor for preventive stuff Part D is  for prescription drugs and then part C  I've had to pull out of order because  it's kind of weird and it's sometimes  called a Medicare Advantage plan part C  is just Private health insurance it just  happens to be approved and slightly  subsidized by Medicare if this all seems  a little confusing don't worry you can  always clear things up by checking the  officialmedicare.gov website like here  on the what Medicare covers web page  which at the time of this video is  published starts with the question is my  test item or service covered and answers  it with the very helpful summary missing  okay to be fair in the month it has  taken me to edit this video so they have  changed the medicare.gov webpage now  instead of saying summary missing it  says nothing after the link you're just  supposed to click the link which is the  more clear thing to do and I'm sure it  is fine because if there's one thing I  know about people over the age of 65  it's that they've never been confused by  the internet this issue with vague  government websites can also be found  with Medicaid since Medicaid is  administered by each state you might  want to check your eligibility for say  Nebraska by going to their website where  it'll tell you you might be eligible if  you are over 65 under 18 or an adult  from 19 to 64. hey Nebraska that's  everyone this might be one reason why  the Biden Administration recently set up  49 million dollars in Grants not for  health care but just to increase  education about who is eligible for  Medicaid currently there are millions of  children who are uninsured in America  but could be insured through Medicaid or  the Children's Health Insurance  reference program but the families just  don't know that they're eligible I  wonder why what's obfuscation  obfuscation is a bit of a  self-referential word because it's  obfuscating a much more straightforward  way to describe this phenomenon which is  called being a little [ __ ] when you  obfuscate something it means that you  are intentionally making it unclear  whether that's through jargon or flowery  speech or just mumbling through your  voice so sorry although this term isn't  exclusive to health insurance I still  feel like it's a good final one for this  video because almost every single thing  about health insurance has been  obfuscated to make it nearly impossible  to get a straight answer it makes you  feel helpless and after the past few  months of researching and writing this  video I'm beginning to think it might be  designed that way oh you're just a  little baby are you just a little baby  you can't even figure out how to get  your own health insurance you'll baby  bye bye HMO plan health insurance  companies benefit by by making you  confused whether that's buying a new  plan that looks cheap but might cost a  ton out of pocket or when your insurance  company says we don't actually cover  that and you have to decide whether it's  worth it to spend hours on the phone  arguing with someone about it or when  you realize that this new doctor that  you need might not be covered by your  current plan but uh oh you missed open  enrollment so you're stuck with it and  it's not just insurance companies some  providers might not be as scrupulous as  you'd like and will take advantage of  your confusion to up charge you on every  minor thing so as a word of advice  always ask for an itemized receipt of  procedures and costs if you go to a  hospital it might make the costs go down  because they don't want to admit in  writing that they charged you 200 bucks  for a smooch on the boo-boo why do I  always default to kissing so oh not now  I really wish I had a good way to wrap  this video up with like a cool quick tip  on how to get the good health insurance  and avoid the bad and also to dismantle  the entire Private health insurance  system but I don't because there isn't  and I I sincerely doubt that there will  be anytime soon if you take a look at  lobbying money health insurance is  always one of the top Spenders Blue  Cross Blue Shield a conglomerate that is  responsible for ensuring nearly  one-third of all Americans consistently  spends about 25 million on lobbying a  year and though I can't say for certain  what that money gets used for I can  promise you it hasn't made this  insurance system any easier to grasp so  much of health insurance something that  is designed to help you navigate the  medical system leaves you entirely on  your own and that's why I think it's  important to have even a little grasp of  what these terms mean and although this  video is predominantly useless I hope  that I've at least made these terms feel  a little less over overwhelming to you  and if I've accidentally made them feel  more overwhelming just know that there  are so many more terms and there is so  much more detail and explanations at  caveats and this is just the tip of the  iceberg for real though it's normal to  feel overwhelmed the system sucks and as  much as I'd like to be able to talk to  someone about this overwhelmed feeling I  have my therapist of the past four years  actually isn't covered by my new health  insurance so oopsie Daisy I made this  video instead but hey we're working  through it together and there are plenty  of healthcare reform advocacy groups  that you can join or support if you like  me would prefer our system to work a  little better for the people it's  supposed to help now if you'll excuse me  I have a shiny new HMO plan and I  haven't had an annual checkup since 2014  so I'm gonna go make the most of it  foreign  [Music]  thank you  [Music]  so you like new around here or you're a  baby right does that mean you know the  Benjamin Button baby oh we've almost  matched we've almost matched Pace all  right you're a little faster than me  okay wait a second and over match of  pace that's what I'm talking about baby  you know the boss baby  is that  because he's like old but he's Young  so funny though I used to think space  was cool I did but then it got because I  got older and then I was like I don't be  in space but now I'm in space and  actually it was kind of nice  you're cool I mean I like you so the  housing Market's better out here  you know because the housing market is  really bad I don't know you might you  probably don't know that because you're  a baby unless you are the Benjamin  Button baby because then you would  because you would have lived a whole  life by then so you would know it  you would know everything you're my  first Benjamin bun baby I ever met  are you Brad Pitt