Maximizing Your Benefits: Make Sure You're Getting the Most Out of Your Healthcare Plan

Open enrollment for health insurance—whether you’re covered by an employer-sponsored plan or a Marketplace plan—can be stressful. The language is confusing, plan provisions often change annually, and premiums go up. But the answer isn’t to sign up for a plan and forget about it. Make the most of your healthcare plan with a bit of research.


Understand coverage options before you choose has a glossary of health insurance terms you need to know, such as “coordination of benefits,” “formulary,” and “out-of-pocket costs.” Refresh yourself on these terms before shopping the Marketplace or your annual enrollment meeting at work.

As you evaluate plans, confirm the following at a minimum:

  • The amount of your annual deductible (how much you’ll pay out of pocket before your insurance begins to cover care at some percentage)
  • Co-payments (what you’ll pay for doctor visits)
  • Whether your current prescriptions are covered in the plan’s formulary (drug list)
  • Your out-of-pocket maximum (how much you must pay out of pocket before your plan pays 100 percent of covered benefits)

Read the “Summary of Benefits and Coverage” (SBC)

Under the Affordable Care Act (ACA), group health plans and health insurance companies must generally provide what’s called a “Summary of Benefits and Coverage" (SBC) that “accurately describes the benefits and coverage under a plan.” The SBC outlines how your plan will cover potential situations, such as pregnancy, or ongoing conditions, such as Type 2 diabetes.

All SBCs are required to cover costs, such as deductibles and out-of-pocket limits, explain the difference between using in-network and out-of-network providers, provide cost-sharing information for “common medical events,” and list both excluded and other covered services.

The SBC must also include “coverage examples” that present hypothetical costs for sample health conditions. The SBC will also have its own glossary based on the uniform glossary.

Choose an in-network primary care provider

Selecting an in-network primary care provider (PCP) is critical not only to maximizing your coverage but also your health overall. You can build a long-term relationship with your PCP, who can provide or connect you to the annual preventive care covered at 100 percent under the ACA, address most medical situations, and refer you to a specialist when needed.

An in-network PCP—one who contracts with your plan—will provide treatment at prices negotiated with your health insurance company, helping you keep out-of-pocket costs down.

Find out which urgent cares are covered

Sometimes you need a doctor when your PCP is closed. As soon as your new plan year starts, figure out the closest in-network urgent care covered by your plan. You won’t want to fumble for passwords when you feel under the weather.

In an emergency, go to the closest hospital. Under the ACA, plans cannot charge more for emergency care from an out-of-network hospital. (But you’ll want to make sure subsequent care is from an in-network provider.)

Don’t miss preventive care

The majority of your routine health care—annual blood work, cancer screenings, routine vaccines, etc.—is covered at 100 percent through an in-network provider under the ACA, so don’t skip this essential preventive care. For women, this includes mammograms, Pap tests, bone density screenings, and FDA-approved contraception.

All Marketplace plans and most other health plans fully cover immunizations for children, as well as important screenings for autism in preschoolers and depression in adolescents. If you have an in-network provider, you have no financial reason to skip this critical health care.

Look for wellness programs and other perks

You can find some fun and savings in your health plan—really! Some plans offer extensive wellness programs where you can earn points for exercising, tracking your diet, or participating in health education. These points can then be exchanged for items such as fitness trackers or even gift cards.

Your plan may also offer discounts on services that aren’t covered, such as vision and hearing care, gym memberships, massage, or telemedicine. Too often, plan participants leave these perks on the table.

As they say, knowledge is power—especially when it comes to your health

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