Choosing a health plan at work can be confusing and often overwhelming. The specifics will vary with each employer, but there are ways employees can evaluate their options to find their best mix of cost and coverage.
Cost for the employee falls into two categories:
1. Up-front premiums.
2. Charges at the time of service.
The premium is the amount taken out of each paycheck for the employee’s share of the insurance company’s charge for the plan. Most employer plans are designed so that premiums are deducted pre-tax, meaning the employee saves on federal income and Social Security taxes and possibly also state income taxes.
Charges at the time of treatment are the out-of-pocket amounts patients must pay to receive medical services. Co-pays, deductibles, and co-insurance can vary a lot depending on the chosen plan and services used. In evaluating this factor, the employee must remember that, under healthcare reform, any service designated by the federal government as preventative should be provided at no charge to the patient.
The cost factor in choosing a plan often comes down to balancing higher premium cost against lower charges for treatment and vice versa. But this relationship between premiums and out-of-pocket does not always hold because of the variable of coverage.
Depending on plan design, coverage will vary among plans in multiple aspects:
1. Is a service covered at all?
2. Is there a cap on the service (number of visits, frequency of tests, etc.)?
3. How much flexibility does the patient have in choosing the provider or opting for a procedure?
4. How often are referrals and preauthorizations required?
Don’t assume a service is covered by all plans just because it is covered by one. If an individual plans to use a particular service, she should review all the plans she is considering to make sure coverage is available for that service.
Perhaps the service is covered but the plan puts a limit on the number of visits. The employee should compare any such limits with his anticipated use of the service. If the plan will not cover his full utilization, the employee must determine if, for him, the extra out-of-pocket expense is worth the service or if another plan is the better approach. Depending on the employer, the employee might also have options such as a Flexible Spending Account (FSA), a mechanism for the employee to set aside pre-tax dollars to use for any medical expenses not covered by insurance.
As a general rule, the more flexibility the patient has to choose doctors and services without getting a referral or preauthorization the higher the premium cost. Plans can range from the HMO, which requires all medical services be arranged through a primary care physician, to a traditional indemnity plan, which places almost no restrictions on where the employee can seek care. The employee must look at her own situation to decide how much choice and flexibility she is willing to pay for relative to the other factors.