Navigating the health care system and making the most of your health care benefits can be daunting. With rising costs and complex insurance policies, it's more important than ever to be an informed and proactive health care consumer.
This guide is the first in a two-part series that will help you better understand and utilize your health care benefits effectively. Let’s begin by gaining some practical understanding of health insurance plans and how to navigate the health care system.
Understand Your Health Insurance Plan
In order to understand the coverage your insurance plan offers, it is important to familiarize yourself with the plan and understand the key terminology insurance companies use. Common terms include:
Premium: The amount you pay for your health insurance every month, or every pay period if it’s deducted from your paycheck.
Deductible: The amount you must pay out-of-pocket for insured health care services before your insurance plan starts to pay.
Copayment (Copay): The fixed amount you pay out-of-pocket for a covered service after you’ve paid your deductible.
Coinsurance: The percentage of costs you pay out-of-pocket for a covered service after you’ve paid your deductible.
Out-of-Pocket Maximum: The maximum amount you will have to pay out-of-pocket for covered health care services in a plan year not including amounts paid as premium..
With these basic terminologies under your belt, take time to review your Summary of Benefits and Coverage (SBC). The SBC provides a streamlined summary of what your insurance plan covers and your anticipated costs. This document will help you clearly understand the exact scope of your coverage. You can create an online account with your health care provider (Priority Health, Blue Cross, Trustmark, etc.) and view a copy of the SBC there. You can also request a copy of the SBC from your employer.
Choose the Right Health Care Providers
Most plans require you to select a primary care physician (PCP) who will manage your overall health care. The PCP is usually your first stop for non-emergency medical care and is the person who coordinates with other health care providers. Your PCP can help avoid unnecessary tests and treatments and refer you to specialists when necessary. You will want to choose a PCP who is part of your provider’s network. You can find a search feature in your online account to make sure your PCP is part of the network.
In-Network vs. Out-of-Network Providers
In-network simply refers to a group of health care providers who have negotiated lower rates with your insurance company. The primary difference between in-network versus out-of-network providers is the amount you’ll have to pay for services. Using out-of-network providers typically results in significantly higher out-of-pocket costs.
Take Advantage of Preventative Services
Most health insurance plans cover preventative medical services at no additional cost to you. Services like annual check-ups, vaccinations, flu shots and screenings (I.e. mammograms, colonoscopies, etc.) are free when delivered by a health care provider within your plan’s network. Utilizing preventive services can help catch potential health issues early and avoid more expensive treatments down the line. Keep in mind that if you have a prior diagnosis or a family history of an issue, a portion of your annual physical or blood work may be billed as diagnostic rather than preventative and therefore you may be responsible for a portion of the cost.
Use Telemedicine Services
Telemedicine has become increasingly popular, providing a convenient and cost-effective way to access health care. Many insurance plans now offer virtual visits, allowing you to consult with health care providers from the comfort of your own home. This can save time and reduce the need for in-person visits, and generally results in improved health outcomes. A virtual visit may also have a lower copay than an in-person office visit.
Manage Prescription Costs
There are three primary ways you can reduce the cost of your essential medications:
Whenever possible, choose generic drugs instead of brand-name medications. The FDA requires generics to have the same active ingredients in the same amounts as a brand-name drug. Therefore, you can trust generic drugs to be equally effective at a reduced cost.
Look into prescription discount programs and apps that can help you find the lowest price at local pharmacies. These programs can significantly reduce your out-of-pocket costs for both brand-name and generic drugs. Some examples of these are GoodRx, SingleCare, and WellRx. You also can check the cost of filling a prescription without running it through your insurance.
Consider using online mail-order pharmacies. Many insurance plans offer mail-order pharmacy services, which can provide a supply of medications at a lower cost. Often, online pharmacies will offer additional services like telemedicine assistance and overnight shipping.
Your health insurance carrier may have a cost estimator available inside your online account. A cost estimator compares the cost of filling a prescription through several different pharmacies in your area. The same prescription doesn’t necessarily cost the same amount at each pharmacy.
If you have a high cost prescription, some pharmaceutical companies have financial aid programs. You can ask your pharmacist about this or contact the pharmaceutical company directly to check on this.
Even if you are familiar with the terminology and practices outlined here, it is advisable to review them on occasion to ensure you are navigating the health care system and your insurance benefits in the best way possible to maximize your insurance coverage.
Be sure to read part two of this discussion, “How to Maximize Your Health Savings Account,” to complete the journey toward understanding your health care benefits.
Do you still have questions? Reach out to your CSI Employee Benefits customer service team (csiinsuranceplan@cebteam.org or 877-274-8796 x 233) should you have any questions or concerns. We have been in your shoes and we are in this together as you navigate your health journey and health plan.