Maximize Financial Savings with Health Insurance
With the consistent rise in insurance premiums being above 4% year over year and an average cost of increase of 7% between 2023 and 2024, it’s important for customers and patients to get the most out of their health insurance plans.
According to the Kaiser Family Foundation’s (KFF) 2023 Employer Health Benefits Survey, annual premiums increased faster this year than in years prior and the most recent increase in premium costs outpaced the increase in worker’s wages and inflation. Ultimately, the cost increases are passed directly to patients and businesses with higher premiums; putting more financial pressure on families and individuals across the US. For the two-thirds of Americans who have health insurance, this raises questions about whether they can afford to pay for health insurance and continue to get value out of this important service.
Hence, it’s becoming more important than ever to ensure you’re getting the most value out of your health insurance plan. Before selecting and subscribing to a health insurance plan, it’s important to read the fine print and consider the benefits of each different tier level and their coverage associations. It's critical to evaluate the plans holistically based on your healthcare needs and not just look at the premium (monthly) costs. When patients use the in-network coverage features of a plans that fall with a higher price and higher coverage tier; the plan with higher upfront costs can more cost-effective. To figure the right plan for your health needs, make sure to compare available options by your employer or consultant, consider the premium, the deductible, copayments, coinsurance, out-of-pocket maximum, and the coverage details for healthcare services that are relevant to your personal or family health needs.
Understanding whether an insurance plan offers the comprehensive coverage you need involves a careful review of key features of the policy which starts by reading through the “Summary of Benefits and Coverage” (SBC), a document that insurance companies are obligated to provide based on government regulations. The SBC document details what services are covered and at what cost.
Most health insurance plans have a list of covered services which should include routine care and preventative care in addition to emergency services, mental health care, prescription drugs and chronic disease management services. The higher priced, tiered plans often are often the most comprehensive in coverage; meaning they tend to cover a broader range of services with fewer restrictions. The Key features that require your attention include the following terms and coverage noted below”
Insurance Terms You Need to Understand
· Deductibles: The amount you pay for covered healthcare services before your insurance plan starts to pay their share. A lower deductible plan can indicate more comprehensive coverage, especially if it applies to a wide range of services. *A deductible is often inversely correlated with your monthly premium payments to have and maintain your insurance plan.
· Copayments and Coinsurance: This is a designated amount owed once the deductible has been met. Understanding what and when copayment and percentages of coinsurance that are due to healthcare providers and the varying percentage of coverage at specialists and general facilities provides patients with the breadth of coverage from an insurance plan.
· Out-of-Pocket Maximum: This is the most you'll have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. A lower out-of-pocket maximum is a sign of more protective, comprehensive coverage.
· Covered Services: Look closely at the list of covered services, which should include not only routine care but also preventive services, emergency services, mental health services, prescription drugs, and chronic disease management. Comprehensive plans typically cover a wider range of services with fewer restrictions.
· Network of Providers: A broad network of doctors, hospitals, and specialists indicates that the insurance plan offers more comprehensive access to care. It's also important to understand the policy's coverage for out-of-network services, as this can significantly affect your costs and access to care.
· Prescription Drug Coverage: Check the formulary, or list of covered drugs, to ensure that any medications you take are covered. Comprehensive plans usually offer a wider range of medication coverage, including brand-name and specialty drugs, with reasonable copays.
· Additional Benefits: Many comprehensive plans include extra benefits such as wellness programs, mental health services, telehealth, and health savings account (HSA) eligibility. These benefits can significantly enhance the value of the plan.
Insurance Plan Tiers & Considerations
Ultimately, insurance is a tool for financial risk management, especially within the context of healthcare. It plays a crucial role in managing financial risks associated with medical care. Considering one-third of Americans are experiencing medical debt and about half of Americans are concerned about going into medical debt as of Sept 2023; Health Insurance helps to individuals and families access necessary health services without facing the catastrophic financial hardship of spiraling medical costs. It’s often helpful to consult with a health insurance advisor or using cost comparison tools available through insurance marketplaces to help make an informed decision when selecting your plan, but below we’ve highlighted some overarching insurance considerations as well as ways that these health insurance plans could be considered cost effective.
· Platinum or Gold Plans on the ACA Marketplace: In the United States, the Affordable Care Act (ACA) Health Insurance Marketplace categorizes plans into metal tiers: Bronze, Silver, Gold, and Platinum. Platinum and Gold plans have higher premiums but offer to cover a greater percentage of medical expenses. For someone who has chronic health conditions or has encountered high medical costs , these plans can be more cost-effective due to their lower deductibles and out-of-pocket maximums.
· Employer-Sponsored PPO Plans: Preferred Provider Organization (PPO) plans often come with higher premiums than HMO (Health Maintenance Organization) plans but provide the flexibility to see specialists without a referral and to receive care from out-of-network providers. For those who need care from various specialists or who live in areas with limited in-network options, a PPO plan can offer valuable flexibility and ultimately save money.
· Comprehensive Private Health Insurance: For those not covered by employer plans or the ACA marketplace, private health insurance plans that offer comprehensive coverage can be a good investment. Though these plans come with a higher cost, they provide extensive coverage and flexibility, which can be crucial for individuals with specific health needs or those seeking the best possible care.
Scenarios Where Expensive Insurance Plans Are Cost-Effective
Even though a monthly insurance premium amount might be expensive, there are scenarios when a high cost insurance plan can be cost-effective; particularly for individuals with specific healthcare needs, those who require frequent medical care, or people at risk for high medical expenses. Below, we’ve pulled together some scenarios where a higher-premium insurance plan may actually save money in the long run:
1. Chronic Conditions: Individuals with chronic conditions such as diabetes, heart disease, or autoimmune disorders often require regular doctor's visits, ongoing treatment, and expensive medications. Higher-premium plans typically offer better coverage for prescription drugs and may have lower copays and deductibles, making them more cost-effective for managing long-term health issues.
2. Family Planning: For those planning to start a family, plans with higher premiums often provide more comprehensive maternity and newborn care coverage. The cost of prenatal care, childbirth, and neonatal care can be very high, and a plan that offers extensive coverage in these areas can significantly reduce out-of-pocket expenses.
3. Frequent Medical Care: Individuals who frequently visit healthcare providers or need regular medical procedures can benefit from a plan with a higher premium but lower copays and a lower deductible. This can reduce the cost of each visit or procedure, leading to savings over time.
4. Prescription Medications: Expensive plans often have broader prescription drug coverage, including brand-name and specialty medications. For those requiring costly or multiple medications, the savings on drug costs alone can justify the higher premium.
5. High-Risk Activities or Professions: People engaged in high-risk activities or professions may face a greater likelihood of needing emergency or specialized medical care. A plan with a higher premium but extensive coverage for emergency services, surgeries, and rehabilitative care can be more economical.
Understanding the Core Features of Your Insurance
Before you start spending or “saving” on your medical care through insurance, it’s important to understand all of your Insurance Plan’s Core Features. You need to read the fine print of your health insurance plan and understand the percentage of coverage of preventative care, specialist doctor visits, hospital coverage, pharmaceutical coverage and mental health services.
Key Features You Need to Know Include:
Comprehensive Coverage: Higher-cost plans often provide more extensive coverage, including preventive care, specialist visits, and mental health services. If you know you need to see specialist doctors or have a condition that requires regular lab work, scans or other medical resources; make sure you sign up for a plan with comprehensive health coverage.
Lower Out-of-Pocket Maximums: Plans with higher upfront deductible costs generally have inversely coordinated lower out-of-pocket maximums, protecting patients against high medical costs from known or unforeseen health issues. If you pay to have good health coverage upfront, you will save money based on the medical treatment you might require.
Prescription Drug Coverage: Often-broad coverage for medications, including brand-name and specialty drugs, can be crucial for those with chronic conditions. If you know you require specialty drugs, make sure the plan you’re subscribing for covers your speciality medications and understand the percentage of coverage and patient responsibility amounts.
Wellness Programs and Benefits: Many higher tiered insurance plans also offer additional benefits such as gym memberships, wellness programs, and free health screenings that can improve overall health and prevent costly medical conditions down the line. Take advantage of these preventative resources provided by your health insurance program.
Navigating In-Network and Out-of-Network Providers
You will also want to understand if your doctors are “in network” or “out of network” with your insurance program.
In Network providers have pre-negotiated rates with your insurance plan where they have confirmed the terms and rate at which they will bill patients. Patients that use in network providers generally control costs better and are liable to spend less money than when they use out of network medical resources.
Out of network providers do not have an agreement with the insurance company and patients will have to cover generally high costs as well as any balances that your insurance program does not cover. Insurance companies also categorize out-of-network providers costs that patients incur with an entirely separate “out of network deductible.” The out of network deductible is often higher than the in-network deductible, so patients have to absorb the provider costs at a greater level than would be expected with in network providers. There’s generally a heavier financial burden on the patient whenever they choose to use an out of network provider.
Finding In-Network Providers: In order to maximize potential cost savings of your health insurance program, you can use your insurance company’s website to identify doctors or medical facilities in network. Even when you use your insurance company’s website though, it’s important to speak to the doctor’s billing office to confirm that they are In network for your specific insurance plan. There are situations where a doctor might accept a certain type of insurance at a macro level for the upper tiers, but doesn’t work with the lower tiered options. Your Insurance customer support or helplines might also be able to help you identify in-network providers and verify coverage before receiving services.
Analyzing Costs and Understanding Your Responsibility
Premiums vs. Out-of-Pocket Costs: Create a spreadsheet or chart where you break down the difference between monthly premiums and out-of-pocket costs, including deductibles, copayments, and coinsurance. You’ll be able to see that oftentimes when you select a plan with higher premiums, you can have lower overall healthcare costs; as long as you need to use those healthcare services.
Understanding the Summary of Benefits: Make sure that you understand the Summary of Benefits and Coverage (SBC) document that outlines what the plan covers and the costs of various services. This will help you understand the copays and percentage of costs where you will be expected to pay. The information in this document should help you understand your different options and where you stand to benefit based on your current or upcoming health requirements.
Get Educated
Once you have all the information, it’s more important than ever to review your current insurance plans, consider your healthcare needs, and explore whether a more expensive plan could save money in the long run by taking full advantage of the benefits offered.
Make sure you weigh what you can afford in monthly premiums alongside reduced healthcare costs of any necessary services you need. The world of healthcare billing and healthcare insurance is complex and confusing. Tricky Bills is able to help our readers understand the nuance and intricacies of insurance plans and medical bills. If you have a specific question, please email us or schedule a call to talk to our medical costs experts.