Just today, I had to acknowledge that my husband was fluent in a language that was totally foreign to me. Specifically, he was reading and understanding the bizarre terms and abbreviations that comprise the sports page in the newspaper. Imagine my surprise when he said that also spoke a language every day that was just as confusing to him – medical jargon.

Perhaps medical terminology is a language unto itself. As with any other technical field, those who are schooled in the language often don’t recognize that it sounds foreign to those outside of the field. The terminology of medical conditions and procedures is unfamiliar to most people and can lead to confusion not only about the treatments, but also about what their health insurance does and does not cover.

While the uproar over the changes in the Medicare "Criteria for Care" a few months ago was well publicized, most people do not realize that these changes are not limited to those persons eligible for Medicare Insurance benefits. Most of the major health insurers have scrutinized these programs and have changed or eliminated certain formerly covered services correspondingly.

Recently, a friend told me that her HMO had increased her out-of-pocket co-payment for prescription medicine from $10 a prescription to 50% of the cost of each prescription! The explanation offered was that another HMO had bought out her HMO and new policies were being instituted. This was not the only change. Not all of the physicians who had been associated with her former HMO chose to participate in the new plan.

Even though she was in the middle of treatment for a serious medical condition, the physicians who were providing the treatment were no longer an available option. The new plan provided a list of other physicians for her to choose from (or to be assigned by the new HMO) who would offer "comparable service".

This type of change affects us all because we choose our health care practitioners carefully and usually choose our insurance coverage based upon whether or not our physicians participate in the plan. For this subscriber however, the HMO shuffle caused a "new deal of the cards" and has changed the game each time that she needs to utilize her health benefits.

What exactly is happening as a result of the movement for national health care reform? Are these changes in health insurance bringing equal treatment and services to everyone? Many patients are finding that their illnesses and conditions are not covered for treatment under their health plans. If they do seek treatment it is considered an out-of-pocket expense that they must bear.

The HMO’s and managed care in general have certainly changed our ideas about what benefits our health coverage will provide. Some of the major HMO/Managed Care companies don’t even provide routine testing and screenings for diabetics as a regular procedure. This seems particularly shortsighted when you consider that the complications from diabetes that is not controlled can lead to strokes, blindness, heart attacks, kidney failure and limb amputations.

Other plans will not cover the prescription of Beta-Blockers for certain heart conditions even though current research reported in the medical journals supports this medication and indicates that it can aid and improve the quality of life for heart attack patients.

Everyone is concerned about finding ways to slow down the runaway train that has produced ever-increasing costs for health care. The current state of the United States health care system, once among the finest in the world, has placed the consumer squarely in the middle. They are walking a tightrope and trying to balance the costs of medical care with the need for adequate benefit coverage.

What can you do in the face of all of these changes?

• Check with your current insurer to see exactly what coverage your plan provides.
• Familiarize yourself with the "standard" tests for certain common diseases and conditions. Are they covered under your plan?
• Does your plan list the co-payments for services or deductible amounts clearly?
• Do you need to obtain pre-approval for services or obtain a referral before seeing a specialist?
• What benefit limits are imposed? Is there a ceiling on coverage?
  (per year, per procedure, or per condition)
• Review other plans and compare the coverage and costs with your present plan.

Do not be put off because you do not understand all of the terminology, either medical or insurance related. Your insurer and your health care provider have an obligation to explain everything in language that you understand.