Deciphering Health Insurance Lingo

Health insurance plans can be intricate and often confusing to decide what is important for your plan. There are many options to cater to what you, the employer, would like to make available to your employees. There are 3 major categories to focus on when looking at health insurance plans:

Health insurance plans can be intricate and often confusing to decide what is important for your plan. There are many options to cater to what you, the employer, would like to make available to your employees. There are 3 major categories to focus on when looking at health insurance plans:

 

1.        Know Your Plan Options:

·         Plan Levels:

o    Bronze –usually designed as high deductible health plans (HDHP) that are generally the lowest premium cost to the member and, therefore, the employer.

o    Silver –wide range of deductibles, copayments and coinsurance. They are a good middle ground for employers to choose between different variables, which in turn can increase or decrease premium.

o    Gold –designed to have low deductibles and low copays, but do often come with a higher premium cost in result.

o    Platinum – These plans generally have a $0 deductible, low copays and low coinsurance for the member. These are the richest plans available for each carrier and come with the highest premium costs as a result.

 

·         Provider Network:

o    HMO – Health Maintenance Organization limits coverage to care from doctors who work for or contract with the HMO, which can lower the premium cost of the plan. It generally requires a referral from a primary care physician and won’t cover out of network care except in an emergency.

o    PPO – Preferred Provider Organizations offer more flexibility. This plan generally provides a broad network that members can use doctors, hospitals, and providers in network for a low cost, but also can use out of the network care without a referral for an additional cost. 

o    EPO – Exclusive Provider Organization offers a plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).

o    POS – Point of Service similar to PPO where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network, but have access to out of network providers. The difference is POS plans require you to get a referral from your primary care doctor in order to see a specialist.  

 

2.        Know Your Plan Details: These aspects of a plan are what your employees are going to utilize. Will your employees benefit more from lower copays or lower pharmacy copays?

·         Deductible – cost that you will have to incur before reaching your plan coinsurance

·         Coinsurance – percentage of post-deductible charges that the carrier and the member are required to pay (example: 80% – Carrier pays 80%, member pays 20%)

·         Rx Plans – Pharmacy plans can often come with a separate deductible and are usually tiered copays based in generic, brand, specialty, etc. 

·         Copays – a flat amount that is paid on a per occasion basis usually for visits to doctors, urgent care, emergency room, etc.

 

3.        Know Carrier Requirements:

·         Contribution – Most carriers have a minimum percentage or fixed amount that employers must contribute towards employee premiums. Most minimums are at least 50% of employee only coverage, this can vary depending on the carrier.

·         Participation – All carriers have a minimum participation requirement. This is determined by the number of employees enrolled and with valid waivers out of the total number of eligible employees.

 

You can now explore the many different carriers and plans available to you with confidence that you will find a benefit that will be appealing to your employees. Stay tuned for my next blog on how to choose a health plan that will help you attract and retain the level of employee best for your business.