Health Insurance Help: How to Live With It and Not WithoutJan 30, 2017 07:59PM ● By Travis Barton
By Mandy Ditto | [email protected]
Even though open enrollment for this year has closed, there are plenty of things to be confused about when it comes to health insurance. Though many people may know the basics about deductibles, premiums and copayments, there are always pitfalls — or just deeper questions — people should be aware of and asking about.
Unfortunately there are times that insurance companies are simply limited, or have created policies that limit them with what they can cover, and people aren’t aware until a medical emergency of some kind comes up and they need help. There are plenty of ways to be prepared, but there are also things people have had to do when some preparation isn’t enough. Here are some professionals’ tips, and personal stories from the Salt Lake Valley pertaining to navigating health insurance.
What everyone should know about their health insurance
The network is the first thing that most people should be looking at when getting coverage, so that they know which doctors and hospitals they can go to for medical attention and help. Most people have a plan from a carrier that makes them stay within in their network to get full coverage, so it’s important for consumers to understand their network bounds.
“A great place to start for people is to look at that network of whatever their carrier is and just go familiarize themselves with ‘What are my network options?’” said Scott Schneider, Vice President of Sales and Marketing for Select Health, an insurance provider based in Utah and Idaho. “Once you already have a plan, it’s important to take a look at what physicians are on there.”
There are a few main ways that carriers explain their plan coverage: a schedule of benefits (or member payment summary for Select Health) and a Summary of Benefit Coverage (SBC), Schneider said.
The SBC is a standard federal form of around eight pages listing benefits of each carrier, but the schedule of benefits or certificate from the carrier sharing exactly what coverage they provide is designed specifically by the company and is shorter and more simple to read and understand, Schneider said.
Becoming familiar with what this coverage summary states is important for those who want to best understand what coverage they have.
Questions that need asking about health insurance
Because it can be intimidating for people to look through their official documents alone, Heidi Castaneda, Small Employer and Individual Plan Sales Director at Select Health, suggests that “reaching out for additional resources is obviously going to be a good idea for some, whether it’s reaching right out to your insurer or agent or broker, to be able to answer some of those questions you might have that are not straightforward.”
Out-of-pocket maximums, deductibles, pharmacy copays, emergency room copays and urgent care costs are some of the specific things people should look at as they go over their SBC and schedule of benefits, Schneider said.
In regards to medical emergencies, people should “get a feel for, ‘Where could I go receive urgent care benefits?’ It’s nice to look at those things while you’re calm, so you could say, ‘Hey urgent care is a $100 visit but the emergency room is $500,’ and go back and say ‘Where is my nearest urgent care unit,’ so they get a feel for what are their copay differentials,” Schneider said.
Something many people may not consider is that they can’t always buy insurance, at any time of the year. Because of the Affordable Care Act, there is an enrollment period that goes from November 1 to January 31, said Robert Sautter, current president of the Utah Association of Health Underwriters. People need to be aware of when they need insurance and when they can sign onto a plan; preparedness for the plan they want is also important, so that they are stuck with what works for them.
Cost is an obvious thing people are looking at with insurance plans and it all depends on one’s needs to decide how much is reasonable to spend.
“People should be looking at what are their needs, are they buying insurance to cover a catastrophic need, in other words do they not have many day-to-day needs, or do you have a common condition to where you need to establish day-to-day care, you need to be covered for that,” Sautter said. “They need to look at their situation, they need to know how much insurance they need. Costs are so high these days, and people will ask to just show them the lowest price product and of course that comes with a high deductible and very high out-of-pocket. The price may be right, but what they realistically need it doesn’t make sense to buy that.”