Health plans certainly come with no shortage of rules. And you’ll want to be sure to follow them in order to get the most out of your coverage.
1) Find the freebies.
If you joined your health plan on or after September 23, 2010, you can get many preventive care services free of cost. Yes, that means no co-pay or coinsurance, even if you have not met your deductible. This includes services such as cholesterol and diabetes screenings, women’s exams, osteoporosis tests, STI (sexually transmitted infection) counseling, immunizations, smoking cessation evaluations, depression screening, many screenings for children, and more. For a complete list, visit www.healthcare.gov.
Even if you were enrolled in your health plan prior to September 23, 2010, the plan may still offer the same preventive care benefits, so it is worth investigating. Check out the “Your Plan” tab in your Simplee dashboard to see details of what your plan offers.
In addition, many plans also offer benefits such as discounts on gym memberships, weight-loss programs, or vitamins. After all, most everything that keeps you healthy and away from the doctor will save both you and your plan money in the long run.
2) Use your network.
If you have an HMO or PPO, your plan contracts with a network of providers. You are probably already aware that seeing physicians within the network will save you money. But plans may also contract with network hospitals, labs for blood tests, medical supply companies, home health providers, or imaging centers. Checking to see if these providers are a part of your plan before going to them for services can also save you money.
And after you have received the service, make sure to check your claim over on Simplee to make sure that you were properly charged.
3) Plan around the deductible.
Many plans have an annual deductible. For example, if your deductible is $500, you must pay $500 out of pocket for your medical care before the plan starts paying for any covered services. If you reach your deductible during the year, it may save you money to take care of any other health needs you have that year, before your deductible renews. Or if you know you will be incurring a number of health expenses that will put you over your deductible, you may want to plan them to fall within the same deductible year so you do not end up needing to meet the deductible twice. If for example you have a calendar-year deductible and you are planning a series of procedures, you may want to avoid scheduling the first in December, in case they lapse into January.
Also keep in mind that some plans may have a separate deductible for in-network providers than for out-of-network providers—you might be starting from zero if you go out of network, even if you’ve already met the in-network deductible.
4) Ask about your drugs.
Every health plan has a formulary, or list of drugs that are covered. Formularies often divide drugs into tiers, or different levels of coverage: For example, a tier 1 drug may have a $35 co-pay while a tier 2 drug has a $10 co-pay. Doctors often have no way of knowing the level of coverage for a drug on your plan when they are prescribing it. Before filling a prescription, you can check the level of coverage with your plan. If it falls on a more expensive tier (or is not covered at all), ask your doctor if there is a similar or equivalent drug you can take which might have better coverage.
5) Understand utilization management.
Many plans now use a process called “utilization management,” where certain procedures must have prior-approval from the plan before they are covered. You should find out if your plan has such requirements. If so, always make sure you have gone through all the steps to get a service authorized before you receive it. Usually, it is up to your doctor’s office to contact your insurance company to start the utilization review, but it is ultimately your responsibility to make sure it gets done.
Above all, the best way to get the most out of your plan is to understand the rules. Every health plan is different. Sometimes, the rules can even be different for two people with the same plan, depending on when each of them joined. You can view all the details about your specific plan when you log in to your Simplee account. If you have any additional questions, call the plan—it’s best to know so you don’t get that surprise bill later on.