Employee benefits renewal season is coming up and a lot of people are signing up for health insurance for the first time, renewing their plans, or looking to switch plans. Typically you get handed a packet with a bunch of choices and are told to pick something. The choices can be confusing and daunting, but if you know a few key pieces of information you can make an informed decision.
Here are some important definitions and the most common terms that everyone should know.
Let’s start with Medical plans:
What do medical plans cover?
They cover things like:
- Visits to the doctor (primary physician, specialists, etc.)
- Emergency care
- Surgeries
- Outpatient care (outpatient means you DON’T have to stay in the hospital)
- Inpatient care (inpatient means you DO have to stay in the hospital)
- Prescription drugs
Depending on your plan, it can ALSO cover:
- Mental health services
- Pregnancy, maternity, and newborn care
- Laboratory services
Now, there are a number of other services that can be covered, but these are what the majority of people will need. On the other hand, medical plans typically DO NOT COVER:
- Cosmetic procedures (enhancements or alterations to your body that are not medically necessary)
- Fertility treatments
- Experimental treatments
In order to find all the details of what your plan covers and what the cost share is, look through the Summary of Benefits & Coverage (SBC). Your HR admin or benefits broker will be able to provide this.
When you are looking at a particular plan, you often see abbreviations like PPO, HSA, and HMO. What do those mean?
PPO - Preferred Provider Organization
Preferred Provider Organization plans are what people consider the “standard” plan. It offers In-Network and Out-of-Network coverage.
EPO - Exclusive Provider Organization
Exclusive Provider Organization plans are very similar to PPOs except they typically have limited Out-of-Network coverage. This means lower costs, but you are restricted to In-Network physicians and hospitals.
HDHP - High Deductible Health Plan
High Deductible Health Plans typically have deductibles in the thousands of dollars. In exchange for a high deductible, the cost of the plan is usually a lot lower. They have both In-Network and Out-of-Network coverage.
HSA - Health Savings Account
Health Savings Accounts can be paired with HDHP plans in order to take advantage of tax benefits. Employees and employers can contribute to these accounts tax-free and they can be used for medical related expenses.
HMO - Health Maintenance Organization
Health Maintenance Organization plans have their own specific network of doctors and hospitals. Ex. Kaiser in California offers HMO plans that limit care to Kaiser’s network. You also need to see your primary physician in order to get referred to a specialist, while other plans let you access specialists directly.
Rollfi has licensed benefits advisors available to help you find the plans that are the best fit for your organization.
