Whether you get health insurance coverage through your employer, you have an individual policy, or you are on Medicare, open enrollment season is right around the corner. There are 3 things you must keep in mind as you make decisions about your health insurance coverage.
1. What’s Covered?
When deciding on a health plan, be sure to review in detail their summary of benefits and coverage. This document should explain in plain language the types of services the plan will cover. It is available through the insurance broker you are dealing with and should also be available on the health plan’s website.
While most commercial health insurance plans will be required to cover 10 essential health benefits (like maternity care, prescription medication, hospital services), some employer plans will not have to offer these benefits. There are also limitation to what Medicare versus a Medicare Advantage plan will cover.
2. Is My Physician/Hospital a Preferred Provider?
Because we live in the aged of managed care, this question is extremely important. If you have a favorite doctor or hospital that you absolutely want to use, you need to make sure that they are considered to be a “Preferred Provider” with the health plan you are thinking of choosing. This means that your provider has a contract to do business with that health plan.
If your physician or hospital is not contracted with that particular health plan, you will be responsible for more, if not all, of your medical bills for that physician or hospital. It can get quite expensive to be treated by a physician or receive services at a hospital that is not contracted to do business with your health plan.
Most health plans have a place on their website where you can enter your physician’s name, or the name of the hospital, to see if they are a Preferred Provider with that health plan. You can also call your provider and ask them if they are contracted with that health plan. But please note that it is important to ask specifically, “Are you contracted with” XX health plan? A provider can say that they “accept” the insurance of a particular plan but not necessarily be have a contract to do business with that plan.
3. How Much Will it Cost Me?
Finally, it is important to understand all of the costs associated with the health plan you are considering. If you want to pay a low monthly premium, understand that you will likely have a higher deductible to meet and a higher out-of-pocket minimum with that plan. If it is important to you to have a lower deductible, you will probably pay a higher monthly premium. Additionally, review the Summary of Benefits and Coverage for the co-payments and co-insurance amounts that are applied to the different types of services provided. For example, there may be no co-payment to see your primary care doctor but a $40 copayment if you see a specialist.
Choosing your health insurance coverage is not a decision to take lightly. Assess your health situation and the providers that you will likely to see and the services you will likely need over the next year as you make your decision. Finally, be sure to ask questions if the health plan materials are not clear. Insurance agents and brokers, employer benefits personnel, and Health Insurance Marketplace Navigators will be available through the Open Enrollment season to help you through the process.