How to Make Sense of Your Employer's Health Insurance Benefits
Copays, and coinsurance, and deductibles, oh my. Trying to navigate your employer's health insurance benefits can feel like getting lost in Oz. But we're pulling back the curtain to help you make sense of your plan. So you can bring your best self to work – and life.
What’s changed since COVID-19 started
The COVID-19 pandemic has changed the way people seek and pay for care through their workplace plans. Exhibit A: Shutdowns and social distancing requirements have led more providers to offer virtual care and telehealth services. Exhibit B: As you may have heard, insurance companies and group health plans are now required to cover the cost of at-home COVID tests. Exhibit C: The gov is taking steps to expand mental health care access and ensure that insurance companies use parity in applying standards for covering mental health care.
What to do if your employer's benefits
options aren’t cutting it
If your employer's benefits fall short of what you need, you could look for another job. Or you could just…ask for new options. Seriously. Consider reaching out to your plan administrator or HR department to see what they can do.
It won’t hurt to do your research ahead of time. Our friends at Eden Health have some ideas for unique employee benefits you could ask for. Plus their own collaborative care offering. They can even work with your existing insurance plan to provide additional benefits. Think: A+ primary care, virtual talk therapy, insurance support, bill advocacy, COVID-19 testing, scheduling support, and specialist referral support.
theSkimm
Insurance benefits shouldn't be a headache. But here we are. Putting aside some time to understand your plan can help you get the health care you need (and deserve). When you need it.
Psst…Wanna learn how collaborative care can keep your mind and body healthy? Eden Health’s gotchu. Oh, and you can get a reward for bringing better benefits to your company by submitting a referral here.
The pandemic also has lots of Americans focusing on health care more than ever
before. And spending more time evaluating whether their lifestyle and work situation
are setting them up to stay physically and mentally healthy. Meaning there’s no time
like the present to learn why benefits are
so important. And ensure yours are working
for you.
How to Make Sense of
Your Employer's Health
Insurance Benefits
First things first, what kind of plan do you have?
HMO
PPO
POS
An HMO (or Health Maintenance Organization for long) limits coverage to “in-network” doctors and hospitals. Aka the ones who have made it official (and maybe even negotiated special rates) with your insurance company. If you go outside that network for specialty care, you’ll need a referral from your primary care physician.
With a PPO or Preferred Provider Organization, you can choose any doctors or providers you want — sans referrals. Buuuut you probably pay higher monthly premiums for that flexibility. And you could still pay more if you pick someone out-of-network.
A Point of Service or POS is a ‘little of this,
little of that’ kinda plan. Because, like a PPO, you can see out-of-network providers and doctors (and maybe even get some of those costs reimbursed). But it’s still usually cheaper to go with in-network options. Like an HMO, you’ll need to get a referral first. Monthly POS premiums typically fall somewhere between that of an HMO and a PPO.
Still got lots of benefits Qs?
We had a feeling you would. So we prepped some answers. Click on any of the below to get the scoop…
Mental health and physical health go hand-in-hand. When your mind doesn't feel good, there's a good chance your body doesn't either. So it makes sense to expect a health insurance plan to meet all of your care needs.
Good news: The Affordable Care Act requires most individual and small group health insurance plans to cover mental health services. Generally, you can expect a workplace plan to offer some level of coverage for:
• Inpatient hospitalization
• Partial hospitalization
• Outpatient mental health treatment
• Emergency care
• Prescription drugs
Ultimately, how much — or little — coverage you have can depend on your plan and what your company chooses to offer.
What kind of mental health services does insurance typically cover?
-
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What should I be looking for in a benefits package?
+
What kind of costs could I be responsible for?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
Where can I find in-network providers?
+
•
•
•
How do I add a family member to my benefits?
-
What kind of mental health services does insurance typically cover?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
If your plan requires you to seek in-network providers, they should have a list you can reference. In most cases, you can log in to your online benefits dashboard and search that list by entering your ZIP code and the services you need.
Once you’ve got a few options, reach out online or over the phone to see when you can schedule an appointment. Don’t have time for that? Some health insurance plans provide scheduling and referral support. Check with your plan administrator to see if yours is one of ‘em.
Where can I find in-network providers?
-
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Not always. Doctors, hospitals, and clinics typically say appointment and service costs vary based on an individual patient's needs. But understanding what your deductible, copays, and coinsurance add up to can give you an idea of what you might be responsible for once you get your bill. You can also ask beforehand whether a service is FSA- or HSA-eligible.
Oh, and always, always, always review your medical bills. Billing errors and discrepancies can mean you pay more than you need to. And they aren’t as uncommon as you might think. If you spot an error, reach out to your provider ASAP to get it corrected.
Lastly, don’t be afraid to negotiate. You can DIY it or ask your bill advocate to help — if your health care plan includes access to one. An advocate could also help with filing claims and appeals. Less paperwork and (potentially) more money? That’s a good deal.
Is it possible to see how much an appointment or service will cost ahead of time?
-
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
Premium. This is the amount you pay every month to have health insurance coverage. (Your employer might pay some or all of this.)
Deductible. Or how much you have to cough up for health care expenses before your insurance kicks in to help out. Psst…it resets once a year.
Copay. This is a fixed amount you pay for a covered service. Your doctor might charge a $25 copay for an office visit or a $5 copay for prescriptions.
Coinsurance. Aka the percentage you pay for covered services after you've met your deductible.
What kind of costs could I be responsible for?
-
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
•
•
•
•
•
•
What should I be looking for in a benefits package?
-
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
Still have lots of benefits Qs?
We had a feeling you would. So we prepped some answers. Click on any of the below to get the scoop…
What’s changed since COVID-19 started
The COVID-19 pandemic has changed the way people seek and pay for care through their workplace plans. Exhibit A: Shutdowns and social distancing requirements have led more providers to offer virtual care and telehealth services. Exhibit B: As you may have heard, insurance companies and group health plans are now required to cover the cost of at-home COVID tests. Exhibit C: The gov is taking steps to expand mental health care access and ensure that insurance companies use parity in applying standards for covering mental health care.
The pandemic also has lots of Americans focusing on health care more than ever before. And spending more time evaluating whether their lifestyle and work situation are setting them up to stay physically and mentally healthy. Meaning there’s no time like the present to learn why benefits are
so important. And ensure yours are working for you.
What to do if your employer's benefits options aren’t cutting it
If your employer's benefits fall short of what you need, you could look for another job. Or you could just…ask for new options. Seriously. Consider reaching out to your plan administrator or HR department to see what they can do.
It won’t hurt to do your research ahead of time. Our friends at Eden Health have some ideas for unique employee benefits you could ask for. Plus their own collaborative care offering. They can even work with your existing insurance plan to provide additional benefits. Think: A+ primary care, virtual talk therapy, insurance support, bill advocacy, COVID-19 testing, scheduling support, and specialist referral support.
theSkimm
Insurance benefits shouldn't be a headache. But here we are. Putting aside some time to understand your plan can help you get the health care you need (and deserve). When you need it.
Psst…Wanna learn how collaborative care can keep your mind and body healthy? Eden Health’s gotchu. Oh, and you can get a reward for bringing better benefits to your company by submitting a referral here.
Inpatient hospitalization
Partial hospitalization
Outpatient mental health treatment
Emergency care
Prescription drugs
•
•
•
•
•
Mental health and physical health go hand-in-hand. When your mind doesn't feel good, there's a good chance your body doesn't either. So it makes sense to expect a health insurance plan to meet all of your care needs.
Good news: The Affordable Care Act requires most individual and small group health insurance plans to cover mental health services. Generally, you can expect a workplace plan to offer some level of coverage for:
Ultimately, how much — or little — coverage you have can depend on your plan and what your company chooses to offer.
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
Workplace health insurance coverage can usually extend beyond the employee. Especially if we’re talking about dependents you claim on your taxes. But there may be rules about who you can add and when you can do it. Here are some instances when you’re likely able to add someone no matter what time of year it is:
Keep in mind: There may be time limits on how long you have to add someone. So it's important to talk to your plan administrator about making a change to your coverage sooner vs. later.
•
•
•
You welcomed a new plus-one to your fam (via birth or adoption)
You put a ring on it (aka got married)
You lost your job….or your
spouse or child under 26 did
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
If your plan requires you to seek in-network providers, they should have a list you can reference. In most cases, you can log in to your online benefits dashboard and search that list by entering your ZIP code and the services you need.
Once you’ve got a few options, reach out online or over the phone to see when you can schedule an appointment. Don’t have time for that? Some health insurance plans provide scheduling and referral support. Check with your plan administrator to see if yours is one of ‘em.
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Not always. Doctors, hospitals, and clinics typically say appointment and service costs vary based on an individual patient's needs. But understanding what your deductible, copays, and coinsurance add up to can give you an idea of what you might be responsible for once you get your bill. You can also ask beforehand whether a service is FSA- or HSA-eligible.
Oh, and always, always, always review your medical bills. Billing errors and discrepancies can mean you pay more than you need to. And they aren’t as uncommon as you might think. If you spot an error, reach out to your provider ASAP to get it corrected.
Lastly, don’t be afraid to negotiate. You can DIY it or ask your bill advocate to help — if your health care plan includes access to one. An advocate could also help with filing claims and appeals. Less paperwork and (potentially) more money? That’s a good deal.
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
•
•
•
•
Premium. This is the amount you pay every month to have health insurance coverage. (Your employer might pay some or all of this.)
Deductible. Or how much you have to cough up for health care expenses before your insurance kicks in to help out. Psst…it resets once a year.
Copay. This is a fixed amount you pay for a covered service. Your doctor might charge a $25 copay for an office visit or a $5 copay for prescriptions.
Coinsurance. Aka the percentage you pay for covered services after you've met your deductible.
There are four main costs to keep in mind when comparing or reviewing your health insurance benefits:
Plans also have an out-of-pocket maximum you’ll wanna take a peek at. This is *surprise* the most you could pay for covered expenses in a year. It’s usually a few thousand bucks. We know, we know. On the bright side: Your insurer will pick up the tab for anything above that amount.
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
If you're evaluating new health insurance options or just trying to make sense of whether your current plan is a good one, you’ll wanna ask the right questions. Like…
• Can I see any doctor or am I limited to in-network providers?
• Is my current doctor covered?
• If I have the option to go out-of-network, how much more will it cost me?
• Will I need a referral to see a specialist?
• Am I covered for prescriptions? What about mental health services? Urgent care and ER visits?
• Alternative services, treatments, or therapies?
• Are any free wellness services or benefits included?
One more tip: Consider whether the plan includes a Flexible Spending Account (FSA) or Health Savings Account (HSA). Either one could help you use pre-tax money from your paychecks for eligible health care expenses. Cha-ching.
What should I be looking for in a benefits package?
+
What kind of mental health services does insurance typically cover?
+
How do I add a family member to my benefits?
+
Where can I find in-network providers?
+
Is it possible to see how much an appointment or service will cost ahead of time?
+
What kind of costs could I be responsible for?
+
What should I be looking for in a benefits package?
+
With a PPO or Preferred Provider Organization, you can choose any doctors or providers you want — sans referrals. Buuuut you probably pay higher monthly premiums for that flexibility. And you
could still pay more if you pick someone out-of-network.
An HMO (or Health Maintenance Organization for long) limits coverage to “in-network” doctors and hospitals. Aka the ones who have made it official (and maybe even negotiated special rates) with your insurance company. If you go outside that network for specialty care, you’ll need a referral from your primary care physician.
If you're evaluating new health insurance options or just trying to make sense of whether your current plan is a good one, you’ll wanna ask the right questions. Like…
• Can I see any doctor or am I limited to in-network providers?
• Is my current doctor covered?
• If I have the option to go out-of-network, how much more will it cost me?
• Will I need a referral to see a specialist?
• Am I covered for prescriptions? What about mental health services? Urgent care and ER visits?
• Alternative services, treatments, or therapies?
• Are any free wellness services or benefits included?
One more tip: Consider whether the plan includes a Flexible Spending Account (FSA) or Health Savings Account (HSA). Either one could help you use pre-tax money from your paychecks for eligible health care expenses. Cha-ching.
Can I see any doctor or am I limited to in-network providers?
• Is my current doctor covered?
• If I have the option to go out-of-network, how much more will it cost me?
• Will I need a referral to see a specialist?
• Am I covered for prescriptions? What about mental health services? Urgent care and ER visits?
• Alternative services, treatments, or therapies?
• Are any free wellness services or benefits included?
If you're evaluating new health insurance options or just trying to make sense of whether your current plan is a good one, you’ll wanna ask the right questions. Like…
One more tip: Consider whether the plan includes a Flexible Spending Account (FSA) or Health Savings Account (HSA). Either one could help you use pre-tax money from your paychecks for eligible health care expenses. Cha-ching.
Can I see any doctor or am I limited to in-network providers?
Is my current doctor covered?
If I have the option to go out-of-network, how much more will it cost me?
Will I need a referral to see a specialist?
Am I covered for prescriptions? What about mental health services? Urgent care and ER visits? Alternative services, treatments, or therapies?
Are any free wellness services or benefits included?
There are four main costs to keep in mind when comparing or reviewing your health insurance benefits:
Plans also have an out-of-pocket maximum you’ll wanna take a peek at. This is *surprise* the most you could pay for covered expenses in a year. It’s usually a few thousand bucks. We know, we know. On the bright side: Your insurer will pick up the tab for anything above that amount.
•
•
•
•
Workplace health insurance coverage can usually extend beyond the employee. Especially if we’re talking about dependents you claim on your taxes. But there may be rules about who you can add and when you can do it. Here are some instances when you’re likely able to add someone no matter what time of year it is:
Keep in mind: There may be time limits on how long you have to add someone. So it's important to talk to your plan administrator about making a change to your coverage sooner vs. later.
You welcomed a new plus-one to your fam (via birth or adoption)
You put a ring on it (aka got married)
You lost your job….or your spouse or child under 26 did
Tap the bubbles to learn more about each type of plan.