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How do I understand my existing health insurance?

If you have any form of commercial insurance (employer sponsored, individual, or co-op), the best place to start is to do a thorough review of your Summary of Benefits & Coverage, which should have a first page that looks much like this …


Example Summary of Benefits & Coverage (page 1 of 8)

The key things that you’ll want to understand about your policy are benefits coverage, total costs, access to your chosen providers, and other intangibles that may be important to you.  And a good way to get grounded on exactly what ‘important to you’ means, do your best at predicting what your next year’s consumption of services and products might mean to you;  are you (and anyone else on the plan) fairly healthy?  Do you have chronic conditions?  Do you have any elective procedures (ie surgical, inpatient hospital stays, etc) that you plan on doing?  Do you have specific primary care or speciality physicians, or hospitals, that you want to ensure are in network for your plan?



What benefits does the plan cover, and what is not covered? Does the plan include Medical Management Programs that are important to you or my family, such as for asthma, heart disease, depression, diabetes, high blood pressure & cholesterol, low back pain, other pain management, or pregnancy?


Total Forecasted Out of Pocket Costs

What are my most likely out of pocket expenses this coming year?  ‘Total’ includes the sum of …

Your share of monthly premiums.  For most of us, this is 100%, but for some, our employers pay a part.

Anticipated use of primary and speciality care, exclusive of annual wellness visits.  Does your past several years help you predict what you’ll use in the coming year?

Anticipated use of elective surgical or inpatient services.

Use of excluded benefits (either intentional or accidental).   How well does your plan cover benefits you anticipate needing?

Use of out of network providers (either intentional or accidental).  Does your plan cover the providers you want to use?  Is the network narrow, and are you at high risk of accidentally or unintentionally using an out of network provider, especially during a surgical or inpatient procedure?


Estimate of Worse Case scenario

What happens if (gulp!) I have to deal with a serious unexpected illness or accident?  What is my plan’s Out of Pocket Maximum?  Is it a narrow network plan, and what is my exposure if I accidentally or unintentionally use an out of network provider or an excluded benefit?  Do I have enough in an HSA, FSA, or other healthcare savings plan to cover?  If not, where would the money come from?



Are the providers (doctors, other medical professionals, and hospitals) that I want to use in this plan’s approved network?  Is the plan’s network relatively narrow, and am I at risk of unintentionally using an out of network provider?



Are there other intangibles about this plan that are important to me? Such as favoring, or ruling out, specific insurance companies, plan types (including HSA eligible), or coverage categories?


Remember:  We coach, support, educate, and empower.  We illuminate options you may not have known you had.  But we don't decide what's right for you in your unique circumstances; only you can do that.  And we don't provide medical, financial, or legal advice; nor do we replace the valuable counsel of those who do.