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Understanding Health Insurance Benefits

Understanding Health Insurance Benefits


Decipher the documents describing your health insurance benefits.


If you’ve ever searched through a health insurance brochure, you’re aware that learning what is covered by your plan isn’t as easy as simply skimming a document.  Many people find out that a medication or service isn’t covered the hard way.  Learning to understand your health insurance is important.  Below is some lingo decoded, and some sneaky clauses to keep an eye out for.



This is the amount that you’ll have to pay before your insurance benefits kick in. If you have a $100 deductible, you’ll have to pay the first $100 of medical expenses for the year out of pocket, and your insurance will start to pay part of your bills afterwards.


Max Out of Pocket

This number is the maximum amount that you’ll have to pay out of pocket for the year. This number is always higher than the deductible. After you meet the maximum out of pocket, your insurance should cover all of your medical expenses. However, it’s important to note that out of network doctors or uncovered medical expenses are often not considered part of the max out of pocket.  Making sure that the services you use and doctors you see are covered and in network is extremely important when you’re planning your healthcare expenses. Premiums are also not included in the max out of pocket.



A premium is the monthly fee you pay to use your insurance.


Multiple Deductibles

It is important to make sure that you understand whether or not you have more than one deductible to meet in your plan. Some plans have a separate deductible for prescription drugs than for medical services and office visits. Knowing how many deductibles you’ll have to meet before your insurance begins covering part of your cost is extremely important.


Mental Health Services

Many health plans separate mental health services from other medical services. While counseling is usually covered under mental health, a psychiatrist is generally considered a specialist rather than a mental health professional. Often this will have an effect on the copay you pay when visiting a mental health professional.


It is also important to know where to go to find in-network doctors, and to know where to look up how different medications are covered. If there is more than one hospital where you live, it is important to know which is the preferred hospital by your insurance to avoid exorbitant fees for medical emergencies or urgent care visits.


Understanding your health insurance benefits is extremely important. Employee Benefit Design is here to help. Our health insurance agents are well versed in area insurance plans. They can help you to decipher the health insurance code and find the plan that will work best for you!



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