A Quick Guide to Understanding Medical Benefits
By: Kimmie Rambol
Insurance is confusing especially when you start throwing out terms like deductible, max out-of-pocket and co-pays, and those are just the start Most employers offer multiple plans to best fit you but how do you pick the best one for you? How do you know what is the right fit? Here are some quick tips and tricks on how to pick the best plan choice for you.
Medical Although there are many types of medical plans the most common are the Preferred Provider Organization (PPO) and High Deductible Health Plans (HDHP).
In PPO type plans you may have a deductible, this is the amount you would pay out of your own pocket before the insurance kicks in, but it is generally only for certain types of procedures. Your regular preventative check ups are normally covered in full by both types of plans. Take full advantage of this! This is your regular check ups each year to make sure nothing is wrong and save you in the long term. A sick visit under the PPO plans requires a copay, this is the amount you have to pay when you are at the office. There can be different copayments for your regular doctor's office, a specialist (like an Ear, Nose, Throat doctor), and an emergency room visit.
In the HDHP plans, you will pay more out of pocket for doctor's visits, but generally you pay less out of your paycheck. Your deductible is a lot higher than in the PPO plan. Your preventative check ups are still covered completely, but a sick visit to the doctors office would have you paying out of pocket.
Key Terms: Deductible: Amount you pay before the insurance covers any costs Copay: Amount you pay at the time of visit, typically a small portion of the total cost of visit set by the employer Out-of-Pocket-Max: the total amount you can pay in a year before all medical procedures are covered completely Co-Insurance: The insurance company pays a percentage of the total bill for any procedure or visit, and you are responsible for the rest
Dental and Vision Dental and vision insurance can be a little more self explanatory, but can have some big differences in coverage from plan to plan.
Dental plans generally have four different factors, preventive, minor restorative, major restorative, and orthodontic coverage. Most plans cover preventative cleanings, and x rays. The main differences between plans in this category is how many times per year you can get cleanings. For minor restorative and major restorative these are covered at a certain percentage, the insurance pays a certain percent of the total bill for the procedure done. Lastly, orthodontic coverage is not a guarantee at every employer. Orthodontic
coverage can be covered at a percentage or up to a specific amount. You also need to ask or check for age limits. It is a common practice to only cover orthodontic work up to age 18 or age 26.
Vision coverage often comes in four parts as well. Firstly, being how often your visits are covered, 12 months or every 24 months are the most common intervals. Secondly, is the frequency of replacement of frames. And the final 2 parts are commonly linked, this being lenses for glasses or contact lenses. Again it normally differs between plans for how often, but also watch for the wording of lenses OR contact lens. Most plans only allow you to get one or the other at their frequency.
Key terms: Minor restorative: the individual insurance companies can select what falls into this category, an example of a common procedure is a basic cavity filling Major restorative: a common example of a procedure that falls into this category is a bridge or a crown.
Insurance is not a one size fits all, and most employers try to accommodate at least two choices for your coverage. There are several factors to think about when deciding on a plan, do you want to pay now or later? This can be the deciding factor between a PPO plan and an HDHP plan. How often do you use your insurance? Do you get sick a lot? Do you get a lot of cavities? And do you wear glasses? Don't be afraid to reach out to your HR department to go over your plan options. There is someone dedicated to going through insurance with the employees. You can also call your company's insurance provider to ask if something specific is or is not covered. Try not to get to wrapped up in the wording and try to look at an overview of the plans, they will generally be easier to understand and cover a majority of the information you will need.