Open enrollment has many small businesses and employees looking for ways to leverage their health insurance options. The enrollment period can mean the difference between life and death for some people, so it’s important to know the ins-and-outs of your plan.
A lot of policyholders haven’t sat down and read through their plan’s policies or terms. If you’re going to learn to use your small business health insurance plan, you have to start by reading first. This means:
Request a Summary Plan Description
A summary plan description, or SPD, can be requested from your policy provider. The SPD is an essential read because it will cover everything that you need to know about your plan, including:
- You need to understand with 100% certainty what your plan’s benefits will cover. If you have a health condition, you want to make sure that, within the scope of your benefits, that it will be covered. If you’re a diabetic, you want to make sure that you can have regular checkups and blood work done. Knowing the extent of your benefits will allow you to know and prepare for out-of-pocket expenses that may occur.
- Loss of coverage. There are terms within the SPD that will also discuss the potential loss of coverage. This information will outline, under what circumstances, you’ll lose your coverage.
- Dependent information. A policyholder that has dependents will need to read through the description to understand who is fully covered under the plan. Perhaps the plan will not cover the same level of a copay for a dependent, you should know all of this information before applying for a plan.
The SPD is a must-read, and while a lot of people don’t read their plan as thoroughly as they should, it’s up to you to educate yourself on the extent of coverage that your plan offers. Oftentimes, you’ll have a lot less coverage than it seems by reading through the basic plan description.
Learn About Your Expenses
Every plan has expenses, and if this is your first insurance plan, you may be under the assumption that a majority of these expenses are covered. The insurance industry is very complex, and the insurer doesn’t want to pay out more than they’re required to as per the plan’s terms.
Some 96% of Americans don’t understand the basics of their policies, but you can if you know your:
- Deductible. Insurance doesn’t kick in automatically. You will have a deductible that needs to be paid, and this refers to the amount that must be paid before insurance goes into effect. This may mean that you’re responsible for paying a certain amount, let’s say $4,000 in services, yourself before the insurer starts paying. Premiums and copays normally don’t count towards your deductibles.
- Co-pay. Depending on the plan, you may or may not be required to pay a co-pay. When reading through your policy’s terms, you may find out that you don’t have to pay a co-pay until the deductible is reached. A co-pay is the amount you’ll be required to pay each visit. You may have to pay $30 for each doctor’s visit, with the insurer covering the rest of the expenses.
- Maximum. Out-of-pocket expenses can add up quickly, and there will be an out-of-pocket maximum that can be reached. This maximum is how much, at the very most, you’ll be paying for services before the insurer covers all of the costs of your healthcare. You may have to spend $5,000+ in just out-of-pocket expenses, on top of your monthly premiums, before health insurance will cover your expenses in their entirety.
- Coinsurance. Let’s say that you have met your plan’s deductible. Now, the insurer will want to pay less than 100% thanks to coinsurance. This term is used to determine how much you’ll have to pay for a doctor’s visit once the deductible is met. A 20% coinsurance, for example, means that you’ll pay 20% of a bill and the insurer will pay the remaining 80% of the bill.
Employers should set up a health insurance plan that best meets the needs of their employees. Every plan is different, and it’s important that small business employers and employees have a full understanding of the expenses that come along with a health insurance plan.
Educate Yourself on How to Appeal a Denied Claim
You’re paying for health insurance, but that doesn’t mean that you’ll never have a claim denied. Insurers have verbiage that will allow them to deny a claim as they see fit. This can lead to unneeded stress and anxiety.
But a little education can go a long way in helping you know how to deal with a denied claim.
The SPD will explain how the appeals process works, so you’ll know how to:
- File an appeal
- Start with supporting an appeal
Your SPD will also explain who to contact in the event of an appeal, so you’ll know who to contact to get the claim approved. Waiting too long to file an appeal is a big no-no. File the appeal quickly, and try contacting the health insurance company before going through appeals.
You may be able to save yourself a lot of time and stress by giving the insurer a call. If an appeal is declined, you will have other options to try and win the appeal, including having a third-party review the claim.
Make sure that you have also checked all of your benefits, keep detailed records before and during the appeals process, and fight to make the most out of your insurance.
A lot of people have health insurance, but never actually use it. When you have health insurance, make sure that you get your annual checkups. If your plan allows for a free annual exam, go.
The worst thing you can do is wait until you’re sick to start using your health insurance. You’re paying for a plan, so take advantage of all of the benefits offered. The same goes for vision and dental insurance, which an employer may offer. Go for an exam, use every last bit of benefits you have – they exist for a reason.
