What you need to know

Although plans are required to be grouped into metallic levels, there can be big differences in plans that may not be obvious. Just looking at the cost of a plan and the quick benefits listed on a website is often not a true picture of the benefits. Often, the lower cost plans have limitations. Following are a few to consider:


  • Provider network – Make sure your provider is in your health plan’s network and the copayment for which you are responsible, if applicable. Some health plans have tiered provider networks where, although in network, you may have to pay a higher copayment for a non-preferred provider. Some plans, like certain HMOs, require you only use in-network doctors and will not cover out of network services. These plans may also require referrals before you can visit a specialist.


  • Prescription drugs – Covered drugs are listed on an approved formulary for each plan. Prescription coverage is not the same with each insurance plan. Some plans may have limited drug formularies. Some medications may require prior authorization or step therapy – a requirement where you try alternatives before the insurance company allows use of your current prescription. Some plans have separate deductibles for certain tiers of drugs.


  • Limited number of visits – Some plans cover the stated copayment for only a few office visits and then are covered after a deductible. Some services have an allowed number of visits per year. If you think you have a need for a special service, check to see how it is covered, if at all.


  • Deductible/out of pocket maximum – A deductible is the amount of money that you are responsible to pay before the insurance plan starts to pay for services. The out of pocket maximum is the maximum amount that you are responsible to spend, typically in a calendar year. This includes your copayments and deductible. Once you meet your annual out of pocket maximum, your health plan will pay 100% of approved in network services for the remainder of the policy year. If you know that you will need an expensive procedure, it is often more cost effective to select a lower out of pocket maximum for a year and then move to a higher limit during the next open enrollment period. The savings can be in the thousands of dollars.


  • Foreign travel – Even for vacations or short visits, some carriers do not cover services internationally. If not, you may want to obtain a short term international travel plan.


  • Dental/vision – These services are not considered one of the 10 essential heath benefits under the ACA legislation (except for children under 18). Some plans do not even offer coverage for children. If you want these benefits, you will likely need to get a separate policy at an additional cost.


  • Cost share reduction – If your household income is between 100% and 250% of Federal Poverty Level based on your household size, you may be eligible for enhanced benefits at a lower cost for Silver plans. Before disregarding these plans as too expensive, review the benefits vs. a lower cost plan.


  • Value added services – Although these are not guaranteed benefits, some insurance companies offer discounts for vision, gym memberships, disease specific services,  etc. If these are of interest, check to see what is available.


There are many factors that influence the true cost health insurance. It is often advisable to realistically determine your need for services and check to see how they are covered to get the best plan for your situation. The licensed agents at Synergy Benefit Advisors can assist you in finding the best plan for your specific situation. Contact us today.