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Understanding your health insurance coverage puts you in the driver’s seat and gives you the confidence to make healthcare decisions that are best for you.
Find out what preventive care is provided, schedule appointments early and check to make sure your providers are in-network.
Providence benefits expert Caryn Vaughn provides advice on maximizing your coverage and saving money.
Let’s be honest: Reading through the details of your health insurance plan doesn’t exactly sound like the most exciting way to spend an afternoon. After all, if your primary care doctor is in-network and your standard co-pay has been the same over the last couple years, what else do you need to know?
By taking the time to refresh yourself on your coverage, you may be pleasantly surprised to find some hidden gems that allow you to activate benefits you haven’t used before.
By taking the time to refresh yourself on the coverage you’ve selected (or are currently selecting), you may be pleasantly surprised to find some hidden gems that allow you to activate benefits you haven’t used before, save money and get the preventive and medical care you need to stay healthy.
We sat down with Caryn Vaughn, benefits director at Providence, who offered some tips and tricks to help everyone — regardless of their plan type — maximize their health insurance.
Know your healthcare plan
When you are well-versed in your plan benefits, you can make better decisions about when and where to get the care you or your family needs. That begins by eliminating assumptions and making sure you know what your plan covers.
Here are a few questions to get you started:
- What type of plan do you have? There are many choices for health insurance coverage, and each offers different benefits. Make sure you know whether your plan is a health savings account, HMO, PPO or another type of coverage.
- What does your plan cover? Get familiar with what you’ll be expected to pay for care. Learn about co-pays for providers and specialists, deductibles, out-of-pocket costs and other coverage details. This will help you avoid surprise bills after you receive care.
- What are your benefits? Look through the “Summary of Benefits and Coverage” to get a comprehensive snapshot. Then, review areas of care you may need throughout the year, like urgent care, emergency care and preventive care.
- Does your plan include dental and vision? Dental and vision are typically supplemental plans but be sure to review those benefits as well. That way you’ll know where to turn for your next dental checkup, braces for your child or glasses for your spouse.
- What are your prescription benefits? Some plans offer discounts for using a preferred mail-order pharmacy. You’ll likely also save by using generic instead of name-brand prescription medications.
- Know your rights. You have the right to fair and easy insurance coverage. That includes coverage for pre-existing conditions, free preventive care and even a translator if you don’t speak English.
Know your provider network
Your plan’s network is a group of doctors and providers that have agreed upon billing a certain amount for care to your insurance company. Doctors, providers and specialists who are “in-network” typically charge you less for care.
A provider who is “out of network” may not be covered at all by your insurance and can result in surprise billing.
A provider who is “out of network” may not be covered at all by your insurance and can result in surprise billing. Don’t rely on the receptionist at your doctor’s office to know that the specialist they’re referring you to is in-network. Always do your research by consulting the provider directory or calling the informational number on the back of your insurance card.
Take advantage of preventive care benefits
Staying on top of your annual wellness visits helps you stay well and live your best life. These benefits are also available free of charge, as required by the Affordable Care Act (ACA), whether your plan is employer-provided, purchased on the marketplace, Medicare or Medicaid. Regardless of your coverage, preventive care benefits may include:
- Annual physical
- Well-woman visits for women under age 65
- Well-baby and well-child visits, up to age 21
- Diabetes screening
- Blood pressure screening
- Cancer screenings for some age groups (mammograms, Pap tests and colonoscopies)
- Routine vaccinations
Learn more about covered preventive services.
Schedule preventive care early in your coverage year
Take advantage of these free services early in the year, or soon after your plan becomes active. Although you may not want to think about your doctor discovering a health condition or recommending surgery, the reality is that some years you or your family members will need more care.
Scheduling your routine visits and procedures early can help you meet your deductible sooner for your coverage period.
Scheduling your routine visits and procedures early can help you meet your deductible sooner for your coverage period. That helps reduce your out-of-pocket expenses in case you need more care later.
You may also want to check your coverage to learn if benefits vary based on in-person visits or virtual care. Some plans offer more convenient scheduling and different copays for virtual care to encourage social distancing.
Manage chronic conditions
If you have a chronic condition like diabetes or high blood pressure, your health plan or employer may offer unique benefits to help you stay healthy and reduce the risk of complications. These may include:
- Diabetes counseling
- Regular blood pressure screenings
- A wellness coach
- Discounted gym membership
Find out how to use healthcare funds
Your plan may allow you to set money aside to help cover healthcare or other related expenses. Be aware of how you are setting aside money and how to access those funds when you need them. Many employers also offer contribution matches so check your balances often and be aware of how much you have available to spend. The most common plans include:
- Flexible Spending Account (FSA): This account allows you to put money into a special “savings” account that you can use throughout the year to pay for certain out-of-pocket healthcare costs like prescriptions, office visits and procedures. The money is tax-free, but it’s considered “use-it-or-lose-it,” meaning you must use the funds within the calendar year.
- Health Savings Account (HSA): HSAs are typically offered with certain types of health plans, like a high-deductible health plan (HDHP). An HSA allows you to set aside tax-deferred money and use it for healthcare expenses, like deductibles, copays and coinsurance. You can keep and access your money at any time, even the next year or after you retire.
Advice from a benefits expert
Although Caryn is a benefits expert at Providence, much of her advice applies to insurance plans in general. We asked her a few questions about what she would recommend for general healthcare consumers.
Q. Are there any insurance changes that have been updated because of COVID-19?
A: Consumers need to talk to their primary care doctor as they will have a universal view of a patients’ situation. During the pandemic, certain plans may offer specific coverage for COVID-19, easier scheduling practices and even discounts for virtual care.
People with chronic conditions really need to plan early so they can live their best lives.
Q. Are there benefits that people generally don’t utilize?
A: People with chronic conditions really need to stay on top of their care. They need to plan early so they can live their best lives. Don’t be afraid to reach out to your carrier to ask questions. There are also some things like translation services, pet insurance and naturopath services that may be covered that people may not be aware of that can offer great benefits beyond their standard healthcare.
Q. What if I don’t have health insurance?
If you don't have health insurance, you can get covered as soon as the first of next month by applying for a plan on the federal exchange at www.healthcare.gov. No qualifying event is required, and many patients can get a plan for $10/month or less with financial assistance. Open enrollment period ends Aug. 15.
When it comes to health insurance, knowledge is power. Understanding your coverage and benefits can help you make informed decisions about the care you receive.
Maximize your insurance to maximize your health
When it comes to health insurance, knowledge is power. Understanding your coverage and benefits can help you make informed decisions about the care you receive. It helps put you in the driver’s seat for your care and your good health.
Insurance benefits can vary greatly between individuals. Your coverage will depend on your situation, such as: the plans your employer offers; whether you purchase insurance through the marketplace; Medicare or Medicaid coverage; and many other factors. The advice in this article is general, but please consult with your plan administration or insurance representative to answer any specific questions you may have.
Find a doctor
If you need preventive care, or are looking for a specialty care, our doctors can help. To find one near you, use our provider directory.
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This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
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