Know Your Plan: How to Make the Most of Your Medical Benefits

No matter what kind of health benefit program you have, if you don’t know how to use it, you’re probably losing money.

Maximizing your benefits and minimizing your costs is all about knowing the “ins” and “outs” of your plan. This means knowing how things work, how much things cost, and what to expect in the event that you have a medical emergency.

Here’s how to get started:

First things first: Need-to-know health insurance terminology

What is my plan’s deductible? (or Initial Unshared Amount)

Your health plans deductible is the amount of money that you will have to pay out-of-pocket before your health insurance “kicks in”.

Having a plan with a higher deductible can create more financial risk, but these plans also have the added benefit of lower monthly premiums. On the other hand, plans with high premiums can have small or even $0 deductibles.  

Switching to High Deductible Health Plans (HDHPs) is an effective way to bring down monthly costs, especially for individuals who can stay healthy and not use their coverage that much.

Qualified HDHP plans also make it possible to own and operate a Health Savings Account (HSA), a valuable investment vehicle designed to work hand-in-hand with your health insurance.

How does my health plan handle doctor and ER visits?

Every plan handles doctor visits and ER visits a little bit differently. Most plans will require an out-of-pocket copay for doctor’s visits, which you’ll need to cover at the time of service. The copay amount is small, usually around $20 for basic things.

Regarding Emergency Room care, you’ll need to know how much money you’ll be on the hook for if you get into an accident. According to the Health Care Cost institute, the average emergency room visit is about $1,500. If you haven’t yet met your plan’s deductible, this is an amount that will be coming out of your pocket.

If you have a high deductible plan and are worried about the cost of an unexpected ER visit, Accident Insurance is something to consider. These low-cost supplementary plans can bring the out-of-pockets costs of an ER trip down to only $100.

Does my plan have a provider network?

Most health insurance companies operate with a provider network. This is a group of doctors, hospitals, and other health care providers that are officially contracted to work with the insurance company or health sharing organization.

When shopping for a new healthcare plan, looking into the plan’s network is an essential step if you’re looking to keep your current doctor.

Some insurance plans will not cover out-of-network services, while others might pay a smaller percentage of the bill than they normally would. In either case, out-of-network care is a fast way to rack up a huge bill.

Does my plan have any preventive benefits?

If you are enrolled in a marketplace health insurance plan under the Affordable Care Act (ACA), then your plan is required to cover a number of critical preventive benefits. These services come with no copayment, coinsurance, or deductible requirement; They’re 100% free to the plan member.

ACA preventive care benefits include:

• Cancer screenings, mammograms, and colonoscopies
• Blood pressure, diabetes, and cholesterol tests
• Routine vaccinations
• Smoking cessation, alcohol dependence, and weight loss counseling

Your health plan might include even more preventive benefits, including gym discounts, fitness memberships, etc. Knowing your preventive benefits is a great way to stay healthy and avoid the costs of getting sick.

Do Health Care Cost Sharing Plans (Healthshare) offer preventive care benefits?

Because healthshare plans are not health insurance, they are not required under federal law to provide access to the same preventive benefits as an ACA plan.

However, more and more health sharing plans are starting to offer preventive care benefits, many of them on par with those offered by traditional health insurance.

To keep monthly contributions low, other health sharing programs are focused on sharing for catastrophic expenses, and let the member pay for checkups and preventive care out of their own pocket.

What kind of telehealth services does my plan include?

Your plan might call it Tele-Health, Tele-Doc, or 24/7 Nursing, but almost every plan in existence offers some form of digital health care.

Tele-health programs can save you a trip to the doctor’s office, even if you’re filling prescriptions or meeting with your primary care provider.

In addition to 24/7 nurse lines, many plans also now include access to an integrated health app. These apps are bringing free fitness classes into member’s homes, as well as other high-tech health tools like trackers, meal-planners, and online health assessments.

Do I have any prescription drugs that need to be covered?

All health insurance plans operate with different list of approved prescription drugs, called a formulary. If you have a prescription drug that you need to maintain your health, you need to make sure that it’s covered by your new plan before making the switch.

In some cases, it’s possible to request an exception to the plan’s formulary, especially if your physician believes the drug is medically necessary.

Some health sharing plans will share expenses for “cure” medications, but not on long-term maintenance medications. 

We’re here to save you money on health care, year after year

If you have questions about your health insurance plan, or if you’re interested in finding a more affordable alternative, give us a call. Your Personal Benefits Manager can help you switch to the plan option that suits you best, whether you’re looking for more coverage or lower rates.

You can also stay tuned to our blog for lots of helpful information on health insurance, health sharing plans, and how to set yourself up for financial freedom in retirement.

Click here to schedule an appointment, or call 800-913-0172 to get started.    

To your health and wealth,

Wiley P. Long, III
President - HSA for America

The HSA for America Maximize Your HSA Newsletter is published monthly and emailed to subscribers at no charge. Subscribe now to stay on top of the critical information you need to know about health insurance, healthshare plans and managing your finances to achieve financial security.