What’s Involved
There are two main factors that will immediately narrow down the essentials of the healthcare plan you need. These are the must-haves when investigating whether or not a plan is right for you: coverage and cost. Under each umbrella, there are a number of specific questions that will pinpoint whether or not you are choosing the right healthcare plan for your needs and budget.
Coverage
Coverage basically refers to everything the plan includes: doctor visits, hospital visits, emergency room visits, prescriptions, surgeries and maternity care, for instance. All of these things will give you peace of mind with the right coverage. But there are essential questions involved to know to what degree your plan will assist in the costs of these benefits.
Which services are covered beyond a basic care plan? And which services are not? Find out if the coverage is limited to only a specific amount of coverage. Ask your potential healthcare provider if the coverage is full coverage or limited to certain costs or beyond a certain threshold. Or perhaps you are keen to have specialist care for things such as from an eye doctor or orthopedic care. These kinds of benefits might be omitted from the list of coverage your potential plan has in store for you – or they could be cost prohibitive.
All of your favorite doctors and hospitals are part of varying networks that are typically covered by one plan or another. The "in-network" physicians and hospitals are the ones your plan covers. Be sure to ask if your favorite doctor or the hospital where specialist care or excellent service exists is a part of the network included in your health plan’s coverage. Nothing could be more disappointing than to sign up for what seems to be a reasonable plan, only to find out that you cannot use it for the doctor you’ve seen for years or the best hospital in town.
Can you use your health care plan’s coverage in another state, or for that matter, in another region altogether? You’re bound to travel at some point. If something happens, are you covered while you’re away? Find out if the plan’s coverage includes out-of-state care as well as international doctors visits, hospital visits, prescriptions and the like.
Are your current prescriptions covered by the health care plan? It’s a good rule of thumb to find out what kind of prescriptions are included in your plan. Maybe there is a nice discount on generic drugs, or you might be able to receive your prescriptions by mail. Will your plan require you to join a specific sort of prescription plan? Find out just how complicated or reasonable your prescription coverage is so that the next visit to the pharmacist isn't a confusing, frustrating – and expensive – experience.
If babies are in the future, you’ll certainly want maternity coverage. An excellent plan will have you covered for all your doctor and hospital visits, exams, and procedures throughout the birth of your newborn baby. Be sure to ask the hard questions of your potential plan to ensure each step of your pregnancy is reasonably covered (i.e. scans, tests, hospital stay, therapies) and that your insurance plan is compliant with your birth plan. It's a good idea to ask about fertility treatment coverage as well if you feel it may be a factor.
Cost
Perhaps the other elephant in the room when considering your healthcare plan is the cost itself. Nothing has been more the subject of a heated political debate than the actual cost of healthcare. You’ll want to save a pretty penny but remain covered when it comes to all of the essential benefits you’ll need to stay at the top of your form.
A premium is the monthly amount you pay for your healthcare plan. What is the monthly premium that you’ll pay for your plan? Perhaps your employer foots the bill. And if they don't, take into consideration what you can afford to pay each month for the coverage that you need. One way to lower your premium is to make one lump sum payment during the year. Perhaps your plan offers you the opportunity to pay once, twice or even four times a year at a reasonable rate, rather than opting for a monthly sum.
How often are you likely to make a claim on your plan? This is also one of the factors that healthcare providers take into consideration when rounding up all the numbers to determine your premium. Sometimes such factors as age, location and smoking, for instance, may mean the difference between a higher and lower premium.
However, don’t confuse a low premium with an excellent plan. Sometimes the lower your premium is, the more you will pay out of pocket for part of your coverage. Perhaps your plan offers a low premium, but because of that, it doesn’t offer a reasonable prescription plan. Not all doctor visits may be covered under the plan’s umbrella. Suss out which premium will give you the best coverage. Maybe you’ll decide to pay a little more out of pocket for certain things like specialist visits, but will rest assured that the essential routine visits are covered. The higher the premium, the more coverage you’ll have and the less you'll pay out of pocket.
Depending on your yearly salary and family situation, you may qualify for a tax credit that can lower your monthly premium. Be sure to check your income bracket you fit in to see if you can put the tax credit to good use.
A deductible is an amount you owe with your health care plan before it kicks in to foot the rest of the bill. For example, maybe your health care plan’s deductible sits at $1,000. You’ll have to cover the costs of anything less than $1,000 until the health care plan takes over for the remaining costs. So if your plan has a $1,000, deductible all your hospital bills, prescriptions, doctors visits, etc. will come out of your pocket until your reach $1,000. However, some plans provide benefits even under the threshold of the deductible. Be sure to ask if your plan offers any perks under the deductible.
A copay is a fixed amount you pay for a service. For instance, doctor visits may be $30 or hospital visits $250. If you have regular doctor visits you’ll want to choose a plan that has a lower copay, so costs don’t add up dramatically. However, take into consideration that your copay shouldn’t discourage you from going to see the doctor. In fact, while a copay helps lower costs for providers, it also can have an impact on the patient’s willingness to find out what that chronic pain is for example. Be mindful of the fact that while you hope to save on costs, don’t skimp on getting the care you need when you need it.
If you ultimately end up with health insurance through your employer, you’ll likely have a managed care plan of some sort:
● Health maintenance organizations (HMOs) keep copays and deductibles down to a bare minimum. But on the flip side, they restrict you to seeing a physician within a specific network. That primary care physician organizes and authorizes all of your screenings, visits, etc. within that network.
● Preferred provider organizations (PPOs) operate under the same sort of guidelines as HMOs but with many more options. You won’t have to worry about your primary care physician acting as the go-between for your scheduled hospital visits and screenings, for example. You can choose within the network of providers for smaller copays and deductibles or outside of the network for a higher price.
● A point of service plan (POS) is a marriage of the two plans. You can choose between an HMO and a PPO whenever you need healthcare. But that also means that your costs will vary.
Ask the Tough Questions
Remember that your healthcare plan is for you, not for the provider. So you’ll want to be at peace, knowing that you reasonably can cover the deductibles and copays involved with each doctor visit. But you’ll also want to make sure you are covered where it counts when the deductible kicks in. Is your favorite doctor included in the physician in-network? Ask these tough questions of yourself as well as of the potential plan. You’ll readily identify just what plan is tailored for you.