Diagnosing Your Health Insurance Plan

By admin
March 24, 2014

Whether you are applying for health insurance for the first time, looking to change your policy for health or financial reasons or simply want to make sure you are getting the most for your premium dollars, there are some dramatic changes in the health insurance industry that will affect how you make your decision. It makes good sense to know what to look for when you compare policies. Even if you already are covered by health insurance, the enactment of the Affordable Care Act (ACA) means your policy is now required to provide coverage that you may not have had in the past.

Let’s face it, most of us are not health insurance experts, so trying to understand what is covered under a policy can be like reading a foreign language. Prior to the ACA many people insured by health care policies thought everything was fine until they actually needed their insurance, only to find they were unaware that a critical service or procedure was not covered. * The following are services and benefits that now must be provided by every health insurance policy:


Essential Health Benefits

• Emergency services

• Hospitalization

• Laboratory tests

• Maternity and newborn care

• Mental health and substance-abuse treatment

• Outpatient care (doctors and other services you receive outside of a hospital)

• Pediatric services including dental and vision care

• Prescription drugs

• Preventive services (such as immunizations and mammograms) and management of chronic diseases such as diabetes

• Rehabilitation services

* There are some exemptions to the above EHB coverage standard. These include grandfathered plans or those that were in existence on March 23, 2010 and haven’t been changed in ways that substantially cut benefits or increase costs for consumers.

Lifetime Limits: The ACA prohibits health plans (grandfathered and non-grandfathered) from imposing annual and lifetime dollar-based limits on essential health benefits.

Cost-sharing Limits: For 2014, the maximum out-of-pocket limit for in-network, essential health benefit expenses is $6,350 for individual coverage and $12,700 for family coverage.

Summary of Benefits and Coverage: Under the ACA, all private health insurance plans must use a standard “Summary of Benefits and Coverage.” Consumers will be able to compare plans side by side because the information will be laid out in the same way, using the same presentation and language.


Some of the important parts to check in the Summary of Benefits and Coverage are:

Household – Make sure the coverage listed is for the correct number of people. For example, if you are looking for family coverage make sure the coverage you are reviewing is not individual coverage.

Deductible – Know the amount you are expected to pay before overall coverage begins. There may be a separate deductible for prescription drug coverage.

Cost sharing – Check the out-of-pocket costs listed for the plan. Read up on any out-of-pocket exclusions. (The terms “cost-sharing” or “out-of-pocket costs” refer to the proportion of your medical bills you will be responsible for paying when you actually receive health care. Cost-sharing never includes your monthly premium.

Find your doctor – Most plans cover a network of providers. Check the network to see if your doctor is included in the covered network. Using doctors out of the covered network will often increase your share of costs dramatically.

Services not covered – Certain services may not be covered under the insurance plan. Make sure you know the services NOT covered before purchasing a plan.

Company information – Look for a phone number to reach the company in case you have more questions about the plan details.

** Preventive services covered under the ACA: All ACA Marketplace plans and many other plans must cover the following list of preventive services without charging you a co-payment or co-insurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.

• Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

• Blood Pressure screening for all adults

• Cholesterol screening for adults of certain ages or at higher risk

• Colorectal Cancer screening for adults over 50

• Depression screening for adults • Diabetes (Type 2) screening for adults with high blood pressure

• Diet counseling for adults at higher risk for chronic disease

• Immunization vaccines for adults – doses, recommended ages, and recommended populations vary: Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis; Varicella

• Obesity screening and counseling for all adults

• Tobacco Use screening for all adults and cessation interventions for tobacco users


Preventive health services for women:

• Breast Cancer Mammography screenings every 1 to 2 years for women over 40

• Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women

• Cervical Cancer screening for sexually active women

• Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

• Osteoporosis screening for women over age 60 depending on risk factors

• Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users

• Well-woman visits to get recommended services for women under 65


Preventive health services for children:

• Autism screening for children at 18 and 24 months

• Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

• Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

• Depression screening for adolescents

• Hearing screening for all newborns

• Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

• Immunization vaccines for children from birth to age 18 – doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis Haemophilus influenzae type b Human Papillomavirus Influenza (Flu Shot) Measles, Mumps, Rubella Meningococcal Pneumococcal Rotavirus Varicella

• Obesity screening and counseling

• Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.

• Vision screening for all children.

**Space prohibited the listing all of preventive services covered without a co-payment or co-insurance, even when deductibles have not been met. Well-Being has included only a portion of those services above. For a full list, visit www.wellbeingmag.com/category/home-kids-pets where this article includes all preventive services in their entirety.


The take-away

When evaluating your current health care policy or looking at new policies you are considering, be sure to take your health provider use patterns into account. Are most of your doctor’s visits the result of common non-serious illnesses or well check-ups? Are you of an age you need more frequent health monitoring visits. If a policy has a higher premium but requires less out of pocket expense, will the number of fully covered preventive care services make up for the increase in monthly premiums? Also consider preventive services that were not covered previously and make sure you are not missing importanat health screens that could identify a problem when it is most treatable. Finding the right health insurance plan is part of taking a pro-active approach to managing your health. If you aren’t sure what your policy covers, this is a great time to give it an annual check-up.

Special thanks to the Mississippi Insurance Department, whose staff members provided Well-Being information for this article.

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