While roughly 90 percent of the population is covered by some form of medical insurance, many insurance enrollees have coverage that they don’t fully understand. Without a full understanding of your benefits, you don’t really have a good understanding of what you will have to pay for when you need to seek care. Likewise, you may not even know where you can go and be treated as a covered patient. Therefore, asking “What will my benefits be?” could be one of the most important questions to ask when picking medical insurance. Here is a look at some of the important questions to ask in the process of enrolling in insurance coverage through an employer-provided program.
What Are the Coverage Options?
Find out what plan options are available and what coverage you qualify for through a specific program. If you have unique medical situations, such as taking a specialty drug or the need for weekly chiropractic visits, you will want to know that those components will be covered by the plan you pick. Likewise, look at what standard visits to a primary physician, specialist, or even emergency room cost you as a member.
What About Deductibles, Co-insurance, Co-Pays, and Out-of-Pocket Expenses?
These questions are important to ask because the answers let you know:
● What benefits kick in at what point
● When you will have to pay costs out of pocket
● If there is a cap on how much you spend out of your own pocket
For example, some “catastrophic” insurance plans may only extend benefits once you have met a high deductible for the year. That means that all costs to that point may be on you as a member. Co-pays will let you know what you will be expected to pay at the time services are rendered. Co-insurance is the percentage of claims you pay after meeting your deductible and before reaching your maximum Out-of-pocket. Out-of-pocket maximums let you know when you will reach a point where the rest of your costs are covered by the insurance.
What Healthcare Providers Can You Visit?
Most traditional medical insurance plans have a PPO network of doctors or care providers. These plans will usually cover more of the costs with an in-network provider than an out-of-network provider. For example, you may see a plan with a $5,000 deductible with in-network providers or a $25 co-pay, but the deductible may be $10,000 and a co-pay of $50 out-of-network. With these types of plans, finding out if your preferred providers are in-network can be crucial; this can make all the difference in out-of-pocket expenses.
Alternatively, if your insurance offers an open-access, no-network plan like ClearChain Health, you essentially have access to any provider you choose. You only need to make sure your preferred provider confirms they will participate with ClearChain Health, and 95 percent of those providers asked will participate. Confirming provider participation with an open-access plan will ensure your costs are as low as possible.
What Is Your Cost as an Employee?
Find out specifically what will be deducted from your paycheck once you enroll in benefits. You need to know how much you are paying to enroll to weigh whether the cost is worth the value of the benefits or if you should seek another option. Likewise, it will be important to know how much the cost will affect take-home pay.
When Will Deductibles Reset?
Deductible resets tend to happen most often on January first of each year; this is a calendar year deductible reset. However, some deductibles reset mid-year when the employer has an off cycle renewal. Understanding when this change takes place can be a huge determining factor for healthcare planning. For example, if you need to have a high-cost procedure done while your deductible is met, you would need to know when the deductible is set to reset.
Getting to Know Your Medical Insurance Is a Must
Without question, having adequate medical insurance is important. Need to see a doctor? The average visit may cost $160 or more. The cost of one emergency room visit can average between $150 and $3,000. Need spinal fusion or a heart valve replacement? The bill could be more than $100,000. With a good understanding of what your coverage is and how your benefits work, you can take advantage of your enrollment to get the most value for your costs.