How the average employee sees health insurance

Like most employees, I chose my health insurance plan based on just a few things – the premium, the co-pays and the deductible. I didn’t research to find out if my primary care doctor was on my plan. I didn’t research what would happen if I broke my arm. I just expected that if I got a cold or had an emergency, that I could show up and my health insurance coverage would be there to fall back on.

Now that I work for an insurance brokerage, I have been well educated on my benefits and all that I was missing out on. What I didn’t know for example, is that our hospital GAP plan (that complements our health insurance plan) provides reimbursement for co-pays on doctor’s visits up to 4 times per year. For me, that means I can go to the doctor for zero out-of-pocket expenses on regular visits for the whole year since I’m NEVER at the doctor that much. If you would have asked me a 6 months ago what the hospital GAP plan covers, I would have answered with a very hesitant: “hospital visits?” Who would have guessed it is so much more than that.

I’ve also learned that our vision insurance doesn’t cover medical problems associated with your eyes. I always thought that if by some freak accident I was to fall down and hurt my eye that I would be rushed to the hospital and my vision insurance would cover it all. But that’s not the case. Vision insurance, in simple terms, covers the things associated with seeing – glasses, contacts, checkups. Your group health insurance plan (or individual health insurance plan) is what would cover an eye injury or glaucoma for example. Neither, sadly, cover corrective laser eye surgery, but may offer discounts.

When it came to dental insurance, I already had a little inside information on claims. Unfortunately, I come from a long line of cavities and root canals. Despite my bad luck, I still didn’t fully understand the differences in a DHMO and a PPO dental insurance plan. I just knew that the DHMO plan would be cheaper per paycheck. Fundamentally, DHMOs usually show you your copays upfront, rather than covering a percentage. You won’t have the freedom of picking a dentist out of a hat on a DHMO dental plan though; you’ll have to choose from a network of providers. With a PPO dental plan, you have the freedom to choose your dentist, but you’ll also have an annual max amount (usually 1,500 to 2,000). In general terms, you’ll likely pay half per paycheck for a DHMO dental plan than you would a PPO dental plan, but may incur more expenses down the line.

Another relatively common type of coverage your employer may provide is short-term and/or long-term disability. That’s only for disabled people right? Wrong. It can be used for severe illnesses, injuries like broken ankles or broken hands, complicated pregnancies… anything that keeps you out for work for longer than 7 to 14 days, but less than 13 weeks. Plan types vary, but these time frames are quite normal practice. Long-term disability kicks in after the short-term benefits are exhausted. Both benefits provide you with a reimbursement of 60% (on average) of your paycheck. So while you are working on getting better, you can stay afloat financially without losing your income completely.

Last, but not least, there’s life insurance. A dreaded topic for most, life insurance is there in the case (yep, you guessed it) you die. Why would you need money when you’re dead? You wouldn’t, but your family WOULD. Funeral expenses, unpaid debts, mortgages, future costs the family may have been relying on your income to pay – all of those things can be paid for by life insurance. If you have children or a spouse, life insurance is a must. I’ve learned that even at the ripe young age of 34, life insurance is a benefit I shouldn’t skip over.

The point is, I was the average employee, with average health insurance knowledge for the first 12 years of my career. I was uneducated on how my benefits worked, and honestly I was never interested in finding out because I wasn’t aware of how much I didn’t know. I’m not advocating everyone go out and work for an insurance brokerage. What I am advocating, is that it’s equally as important for employers to educate their employees on these valuable benefits as it is for employees to take the time to understand them.

All too often we get questions about why claims weren’t covered or why there’s a bill for a physician’s fee when you’ve already paid the co-pay. It’s not rocket science, but group health insurance coverage definitely isn’t the easiest to understand. Being well versed in your benefit offerings is the duty of any good HR manager, but your benefits broker should be your fall back when more complicated questions arise.

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