Know These 5 Things About Your Health Plan
In a healthcare system where people may change insurances as often as they change jobs, or more (if your employer is acquired or choose a different health plan), it is important to knwo the facts about your particular health insurance. The health plan that you choose will likely provide an introductory packet, and hopefully your employer provides an outline of what is covered and what is not.
How you do, as a savvy consumer of healthcare, sift through the noise and identify those things that you really need to know? We've identified the five things that you need to know about any health plan you are a part of. Hopefully, of course, you know more than these five things about your insurance. If you can only know five, though, here they are:
1. Do you have a network or a primary care physician (PCP)?
Perhaps the most critical thing to understand is if you need to go to a certain physician or healthcare network to seek your care, or if you can see anyone you wish. If you are required to go to a certain network, are the physicians that your family normally sees included? If you are required to go through a PCP, can you arrange it so your preferred doctor is the one? These are things that you want to have answered before you need to make that priority appointment to have the pain in your abdomen checked out.
2. What is your deductible / copay arrangement?
This is important for two reasons. First, whatever you expect to spend on deductibles and copays for the year should be factored in to your Flexible Spending Account (FSA) allocation for the year, assuming your employers offers one. Second, as you receive bills from your doctor, clinic, or hospital, you will want to have a thorough understanding of what your share of the payment should typically be. If you know that you have a $20 copay for any office visit, and you get a bill from your doctor for $87.45, red flags should go up.
3. What basic medical service are / are not covered?
Some medical plans don't cover preventative care. In those situations, you may have an opportunity to "buy-up" to a plan that does, or your employer may offer preventative coverage through a different administrator. Similarly, if you are a heavy user of a basic service, such as a recurring therapy, you will want to due your homework to make sure that you understand how your health plan will cover it rather than being surprised when the denials begin coming in the mail.
4. Does it include dental / vision / pharmacy?
Not every employer offers dental and vision, and many who do offer it under a different insurer with different medical cards, etc. Be sure to know what health plan covers what service. Not doing so can lead to you providing the wrong insurance information to a provider, which in turn leads to a long and protacted process of getting the claim paid, which you will find yourself in the middle of.
5. What are the authorization requirements?
We talk about this in more detail in our Prior Authorization section, but it is critical that you understand when authorizations are required for medical services. Failing to obtain a prior authorization when one is needed can result in a large medical bill coming your way, one that could have prevented with a little research and action.