If you have multiple medical plans available at work, you will have to balance cost and coverage while making your choice. The best plan for your situation is not always obvious. Things can get even more complicated if your spouse or partner also has access to health insurance or if you have children.
Definitions – A Few To Get Started
Premium: The amount taken out of your paycheck. The health insurance policy costs your employer a certain amount per person. They likely pay for part of that cost, leaving you to pay the balance.
Out-of-Pocket Costs: What you, or your covered family members, have to pay when you go to the doctor, get a prescription, or use any other medical services.
Provider: Any person, hospital, pharmacy, or other entity you go to for medical services.
Coverage: What the health plan will pay for.
Gatekeeper: A person or organization that must approve medical care before you can get services. Often your primary care doctor, but might also be the insurance company.
Premium vs. Out-of-Pocket Costs
You will usually see the relationship between premiums and out-of-pocket costs be something like
Lower Premiums = Higher Out-of-Pocket
Higher Premiums = Lower Out-of-Pocket
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Understand your risk tolerance.
You’re often making a decision at this point between the known amount per paycheck and the unknown of future medical bills. Do you prefer to have the lowest possible deductions from your checks? You might have to take on the risk of higher expenses down the road if you get sick or are injured. But if you want more predictable expenses, a plan with lower out-of-pocket costs might be better for you.
What medical expenses can you predict with certainty? Look back at any records you have for the past year to see what your health costs were for the household. If you or a family member have a chronic health condition, make sure you find out the cost of the services you will need.
What a health plan will pay for is as important as how much it will pay. Look over the information you receive to make sure you understand the services covered. Just because your employer offers four plans doesn’t mean each will pay for the same services. Compare the coverage details using several factors:
- Will the plan pay for a service at all? For example, not all health insurance plans pay for infertility treatments or will pay for only certain types of treatments.
- Will you face a limit on the service, even if it’s covered? You might get only a certain number of chiropractic visits each year, or maybe you have to fit all of your physical therapy sessions into a 60-day window to get coverage.
- Do you have to go through a gatekeeper for medical service? You’re probably familiar with getting referrals from a primary care doctor to see a specialist, but many insurance companies now require preauthorization before you can get particular tests or prescriptions for certain drugs. Different plans will give your more or less freedom to choose your care without going through a gatekeeper.
Health plans come in several general types, and each type tends to have a different mix of cost and coverage (variation in #3 above is key). We’ll talk about these types in the next post!
Up next: Different Types of Health Plans