Photo by Ben Roffer
So, Healthcare.gov is up and running, and you’re all excited about picking out health insurance, huh? Well, the site is working, but picking a plan can be brain-splittingly complicated (I nearly split mine doing research for this article), especially if you’re relatively healthy and grumbling about how you’ll never need the stuff anyway. But, if you ride a motorcycle, you can’t ignore the fact that your odds of needing healthcare just went up a little. Here are few things you need to consider:
HMO vs. PPO
Health Maintenance Organizations (HMOs) focus on wellness. Preventative care and routine visits to your in-network provider are usually well-covered, with less attractive coverage for episodic acute care, diagnostics and the dreaded out-of-network provider. At face value, they often look like the cheapest route, but only when using in network providers: hospitals, labs, imaging centers, emergency medical transport services, pharmacies, therapists...all who have agreed to accept negotiated (lower) rates for whatever service. Stray outside the network, and coverage can be minuscule. HMOs tend to be more restrictive when it comes to seeing specialists or obtaining expensive diagnostic exams or treatments, and might not approve your provider’s recommendation until it can be reviewed by their own auditor (who may or may not be a physician, by the way). Get used to things like needing “prior authorization” before procedures and/or diagnostics, and needing a trip to your primary care provider before getting a pass to see a specialist.
Preferred Provider Organizations (PPOs) also favor in-network providers, but may have slightly higher monthly premiums and co-pays in lieu of less restrictive management. They tend to have a larger pool of participating providers (because reimbursement rates are better) and less disparity between in and out of network coverage.
Implications For Riders: Injuries from a motorcycle accident typically cost more money to diagnose and treat than a typical trip to the doctor’s office. They’re also less amenable to choice when it comes to where you get the care you need. Consider what you’re most likely to need health insurance for: management of a chronic problem vs. treatment for an acute illness or injury? Also consider what kind of riding you do: touring (out of network or out of state?) vs. commuting (where in-network coverage is readily available)? Consider if any of this even matters to you, or your family, or whoever ends up getting stuck with the bills if you have a serious collision.
Photo by Eric Schmuttenmaer
What About The Deductible?
This is the amount you have to spend (per calendar year) on eligible expenses before your insurance kicks in. This does not include what you spend on monthly premiums and co-pays. You’d like to think it’s that simple, wouldn’t you? It’s not. Each plan describes what can and can’t be applied to your deductible, and each defines “eligible expenses” differently. You literally have to read each and every plan’s definition. Yes, really.
Implications For Riders: One trip to the ER for a motorcycle accident is likely to take care of you entire deductible. Ouch. And, yay!
Continue Reading: The Motorcyclist’s Guide to Health Insurance >>
Out-of-Pocket Maximums: This is a nice number; the lower the better. Like some glistening beacon twinkling with promise at the end of the dark, scary, fire swamp of insurance plan comparison hell, this amount is the most you’ll pay per year for health-related expenditures. It includes what you fork over in co-pays, out-of-pocket expenses, and that big deductible. It does not include your monthly deductible. Nothing does.
Implications For Riders: All those things that aren’t covered by your plan (like that hand-carved knotted-pine cane or having Helga, your private duty physical therapist come to your office to work the bejesus out of your rotator cuff twice a week) get lumped into this pile. Sadly, the lower your out-of-pocket maximum, the higher your monthly premium. Darn.
Photo by Kristine Laprise
Co-Payments and Co-Insurance: This is what you’ll pay every time you show up somewhere needing something from someone wearing rubber gloves. Rates are all over the map, from zero to what-the-heck-am-I-paying-you-for-every-month?
Implications For Riders: Here is where you find out how much the ER is going to cost you before you even set foot in the door. Pay close attention to this number.
As for a trip to the ER, if you need it, you need it, but coverage varies widely by plan. Co-pays are typically a couple hundred dollars, but can be way more if your plan is a stickler for in-network facilities. If you’re in any shape to request, and/or it’s medically safe to do so, EMS will usually transport you to the facility of your choice (within reason of course; they’re not taking you to Johns Hopkins in Baltimore when you crash in Philly). The transport service by the way, is an entirely separate cost.
For injuries that do require immediate evaluation, you’re most likely going to get sophisticated diagnostics (CTs, MRIs, etc.) and a handful of physicians in different specialties meddling with you. Consider this scenario: you have a nasty high side on an otherwise perfect track day. You’re bell was rung, and you wake up dazed and confused in the ambulance. You’re in a collar, and your hip hurts like a son-of-a-gun, especially when you try and move your leg. Good news! You’ve got a concussion, a C7 spinous process fracture, and the pelvic hematoma that ate Manhattan! You’re going home with some Percocet and a bag of ice, but not before you’re seen by the ER doc, a trauma surgeon, a radiologist (who doesn’t actually see you, but reads your imaging studies), a neurosurgeon, an orthopedic surgeon, and a hospitalist. Congratulations on meeting your annual deductible in one fell swoop!
Photo by Jan Ivar Sørensen
What About Exclusions? It’s common for plans to exclude coverage for things like elective cosmetic surgery and dental work, but there’s usually more buried in the proverbial fine print. These are things that too often aren’t realized until you get that bill in the mail that triggers immediate chest pain and palpitations (relax, everyone covers that). Insurance companies can be equal opportunity discriminators. Just like some plans won’t cover family planning (based on your employer’s religion) or abortion services in the case of rape (Michigan), some plans might not cover healthcare costs incurred from riding your motorcycle. Or being on the back of someone else’s. Or if you weren’t wearing protective gear when it happened. Or if you were skiing or bungee jumping or T-boned by a UFO. Coverage for things like physical therapy, home health care, certain drugs, and all kinds of unexpected health-related things may be minimal or non-existent. The only way to know this is to read your policy. All of it.
Implications For Riders: Motorcycle injuries are expensive, and the worst of them can render you worse than dead. Medical costs for the first year of a severe traumatic brain injury average over a million dollars, with annual costs thereafter of about $100,000 per year. Did I mention almost all plans have lifetime maximums? Mitigate your risk by picking a health plan that provides the best coverage for what you’re most likely to need, never riding without proper motorcycle insurance, signing up for a MSF Riding course, and by wearing all the gear, all the time.
Now...about that smoking habit of yours...