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Life Health > Health Insurance > Health Insurance

6 health insurance basics your clients should know

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There are more debates going on in the country than just the presidential debates when it comes to health care.

Individuals, families and small businesses are debating amongst themselves and their peers what health care access and costs mean to them; what they are willing to exchange to have health care; the “price” they are willing to pay for health care and what that “price” means.

So when your clients are thinking about health care you might encourage them to look at these six things they should know about health insurance.

1. Know what their plan would do if they were admitted to the hospital.

Your clients should know their out of pocket maximum.

If they’re in an HMO or PPO plan, make sure they not only have an out-of-pocket maximum in-network but that they also have an out-of-pocket maximum out-of-network.

Does their plan limit access to certain procedures, such as transplants?

2. Know their deductibles

Deductibles can be written two different ways:

The deductible can apply to the client’s whole plan (things inside and outside the hospital). In that case, the clients should take a low deductible.

With a $500 deductible then each family member would have to incur $500 in expenses before the insurance would pay anything. A family of four would have a $2,000 outlay. They could go years without ever using their insurance.

Or, the deductible can apply to a hospital admission or things like surgery. Things outside the hospital can be no deductible, a co-pay or smaller deductible.

When was the last time your clients were admitted to the hospital?

If they were admitted to the hospital, they will probably hit any deductible they choose anyway.

The real question is what their coverage is going to do after the deductible has been met? Is the plan 90/10, 80/20, or 60/40? Deductible and percentages are simply insurance selling tools.

Say they have a $500 deductible and they have an 80/20 plan. What would happen when they have a $100,000 claim?

They would end up paying 20 percent of $100,000 minus their deductible or $19,500. It wasn’t the deductible that hurt; it was the percentage of co-insurance they were left to pay, right?

Would they rather have a $5,000 deductible on a 100 percent plan or a $500 deductible on an open-ended 80/20 plan?

Particularly if their deductible was for the major things like the hospital stay, they could put other things on their plan to cover day-to-day medical expenses, with no deductible, a co-pay or a much smaller deductible.

3. Know how their plan would handle outpatient surgery, chemo and radiation.

There is a big difference between in-patient (being in the hospital) and outpatient coverage.

Most insurance plans say they will cover chemo, radiation, etc. under any hospital admission. The key word being hospital admission.

The only problem is that most chemo today is not given in a hospital admission. If you had cancer you could go into the hospital. You might be there a week or 10 days. They may do surgery and they may give you a pop of chemo while in the hospital to see how you react to the chemo. Then you’d be released from the hospital. They will set you up for future chemo treatments. These treatments will be administered on an outpatient basis and typically not covered.

4. Know how their plan covers drugs

Especially maintenance drugs.

Clients should know their drug card’s limit and understand what would happen if they were to hit that limit. What is their plan of action?

If they have a drug card on a plan, know what the annual limit per person is.

Many drug cards have $300 limit per person, or some similar amount or restriction.

If all your client ever does is pick up a one-time antibiotic, that’s fine. But what if they are on some type of maintenance medication, heart meds, cholesterol, diabetes, etc.?

5. Know what their plan would do in regards to outpatient testing, therapy, or ambulatory care

Most plans give your client a co-pay at the doctor’s office.

Is that $50 or $90 doctor visit why they bought health insurance?

The real concern may be what if that doctor starts running a bunch of test? The test may fall under the category of ambulatory care. Most insurance plans will give them a doctor co-pay; however, tests are not typically covered.

Would your client prefer to pay a $50 or $90 doctor visit and let the insurance company pay for that test, the test interpretation, that physical, occupational or speech therapy? What would seem more reasonable to your client?

And be careful about daily limits.

6. Does their plan cover them “on and off the job”?

Companies with four or more employees are required to carry workman’s compensation.

Consequently, many health insurance companies write their plans in such a way that they don’t cover you while you’re at work.

Very few self-employed individuals carry workman’s compensation insurance. Even if they have four employees they tend to carry workman’s compensation on the employees and opt out for themselves.

Where do they have a better chance of getting hurt, at home in front of the TV with the remote or at work? Often self-employed persons find out their health insurance did not cover them at work when they first visit the emergency room.

The hospital asks your clients for their insurance card, then they ask if the injury occurred at work.


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