My Benefits Primer

Choosing Health Benefits

Remember, health benefits can greatly impact your overall financial health. Choosing health benefits can be a complex process, but planning well can make a big difference. And in most cases your decisions last for a full year, so making well-informed selections is important. Plan for Your Health's Navigating Your Health Benefits helps you make the most of your health benefits at key decision-making points.

Open enrollment

It's that time

Open EnrollmentOpen Enrollment
A time, often in the fall, when employees choose their health plans for the following year. You typi... more
is the time, typically from October to December, when millions of Americans have the opportunity to reevaluate their benefits and make changes for the following year. The challenge is spending the time reviewing and understanding the materials provided. The glossary on PlanforYourHealth.com or your benefits administrator at work will help you make sense of terms and information with which you may not be familiar. And here are some important things to consider when re-evaluating your health benefits:

The Four "C's" of Open EnrollmentOpen Enrollment
A time, often in the fall, when employees choose their health plans for the following year. You typi... more

  1. Cost of premiumspremiums
    The amount charged by a health insurer for a health insurance policy. If you have a health plan thro... more
    and co-payments
  2. Coverage information including in-networkin-network
    Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
    doctors
  3. Current plan options; these may change from year to year
  4. Choices such as Health Savings AccountsHealth Savings Accounts
    This savings account allows people to pay current health care costs or save for future expenses. To ... more
    (HSA), Health Reimbursement ArrangementsHealth Reimbursement Arrangements
    This is an employer-paid account for employees and retirees. The funds are generally available to pa... more
    , Flexible Spending AccountsFlexible Spending Accounts
    A FSA is an account tied to an employer-sponsored health plan. It can be used to pay for medical exp... more
    (FSA), long-term care and life insurance

Questions to ask

Here are some questions you should ask yourself when choosing a health insurance plan:

What will this plan cost?

  • What is the monthly premium?
  • What are my co-pays or deductibles with this plan?
  • After I've met my deductibledeductible
    A set amount that you must pay for your medical services before the health plan starts to pay.... more
    , what percentage of my medical expenses is reimbursed?
  • What is my maximum out-of-pocketout-of-pocket
    Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
    cost?
  • How much less am I reimbursed if I use doctors outside the health benefitbenefit
    The term "benefit" may refer in general to a health plan (your "benefits"), specifically define the ... more
    providerprovider
    A licensed health care facility, program, agency, physician or other health professional that delive... more
    's networknetwork
    Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
    ?

Does the plan cover the services that are important to me?

  • Are the doctors, hospitals, laboratories and other health care providers that I use in the health benefitbenefit
    The term "benefit" may refer in general to a health plan (your "benefits"), specifically define the ... more
    providerprovider
    A licensed health care facility, program, agency, physician or other health professional that delive... more
    's networknetwork
    Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
    ?
  • Am I allowed to see a doctor outside the networknetwork
    Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
    ? If so, what is the reimbursementreimbursement
    Payment from a health benefits plan to reimburse an individual's covered medical expenses or directl... more
    difference?
  • How easily can I change my primary care physician?
  • Do I need to get a referralreferral
    In some health plans, you must receive a referral from your primary care doctor to see a specialist ... more
    in order to see a specialistspecialist
    A physician who provides medical care in a medical or surgical specialty or subspecialty (for exampl... more
  • What are the procedures for getting care and being reimbursed in an emergencyemergency
    A serious medical condition resulting from injury or illness that arises su... more
    situation, both at home or out of town?
  • Does the plan pay for preventive health care such as diet and exercise advice, immuniza-tions and health screenings?
  • If I have a preexisting medical condition, will the plan cover it?
  • If I have a chronic condition such as asthma, cancer, or diabetes, what special services or programs are offered to me?
  • Are the prescription medicines that I use covered by the plan?
  • Does the plan reimburse alternative medical therapies such as acupuncture or chiropractic treatment?
  • Does the plan cover the costs of delivering a baby?
  • What additional programs and services does the carrier offer? (i.e., wellness programs, weight management programs, disease managementdisease management
    A program for identifying individuals with a specific illness or disease (usually chronic in nature)... more
    )

Eligibility

If you're new to a plan, make sure to confirm when you will be eligible for benefits, and when your coverage will begin

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Major life events

Switching jobs?

Just as you would at any new job, evaluate your health benefits planhealth benefits plan
A plan purchased by an individual or provided through an employer that provides payment for health c... more
by considering cost (premiumspremiums
The amount charged by a health insurer for a health insurance policy. If you have a health plan thro... more
, co-payments, deductibles and co-insuranceco-insurance
The portion of the cost of covered medical services paid by the patient under a health plan, after f... more
), coverage (in-networkin-network
Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
doctors, prescriptions, vision/eye care) and the availability of options such as Health Savings AccountsHealth Savings Accounts
This savings account allows people to pay current health care costs or save for future expenses. To ... more
(HSA), Health Reimbursement ArrangementsHealth Reimbursement Arrangements
This is an employer-paid account for employees and retirees. The funds are generally available to pa... more
, Flexible Spending AccountsFlexible Spending Accounts
A FSA is an account tied to an employer-sponsored health plan. It can be used to pay for medical exp... more
(FSA), long-term care and life insurance. Some additional elements to keep in mind:

  • You keep your HSA - a tax-advantaged savings account that you can use to help pay for qualified health expenses - when switching jobs or health plans. Be sure to keep the account alive and continue deducting medical expenses, or save the money for future health care spending.
  • Going without health insurance, even for a short time, puts you or your family at serious financial risk. So if you're between jobs, visit the U.S. Department of Labor's website for information on temporary coverage.

Getting married?

Once the honeymoon is over, it is time to get down to business and learn how to make your benefits work for both of you. More than likely, you both have benefits and need to compare the two plans. When deciding if you want to stay on your own plan or join your spouse's or your partner's, you need to decide what is most important to you:

  • How comprehensive do you want your health insurance coverage to be? Are additional services provided such as coverage for dental, vision care or prescription drugsprescription drugs
    Medicine that requires a doctor's permission to buy. These drugs are different from over-the-counter... more
    ?
  • Would you like to be able to choose a specific doctor or hospital? What doctors and hospitals are covered under each plan?
  • Is it important to visit health care facilities that are close to your job or home?
  • How much are you willing to spend on premiumspremiums
    The amount charged by a health insurer for a health insurance policy. If you have a health plan thro... more
    and deductibles? Are there co-payments or co-insuranceco-insurance
    The portion of the cost of covered medical services paid by the patient under a health plan, after f... more
    for routine and emergencyemergency
    A serious medical condition resulting from injury or illness that arises su... more
    care?

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Having a baby?

One of the best ways new parents can protect their financial future is to plan for their family's health. Having a baby - even if it is your second or third child - is the perfect time to take a fresh look at your health benefits and overall budget.

  • Do I need to make any changes to my health benefits? Yes, you will need to declare your child as a dependentdependent
    A child or spouse who gets health insurance coverage through your plan. Often times there are limit... more
    on the policy. Check with your health planhealth plan
    A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
    providerprovider
    A licensed health care facility, program, agency, physician or other health professional that delive... more
    to find out when you should enroll your child in the plan.
  • What kinds of costs do I need to plan for? You'll need to plan for visits to your physician and the associated co-payments or co-insuranceco-insurance
    The portion of the cost of covered medical services paid by the patient under a health plan, after f... more
    . You should also consider the cost of delivery, which will vary depending on the delivery method and the hospital or birthing center. Take into account the experts you may want to consult, such as a doula, midwife or lactation consultant. To get an estimate of the total cost, check out the Baby Expense Calculator on PlanforYourHealth.com.
  • Check if experts' services are covered by your health planhealth plan
    A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
    , and if they have a list of pre-ferred providers with discounted rates.

On your own - how to buy your own benefits

The circumstances of your life can determine the type of health coverage you need. Visit Plan-forYourHealth.com to identify a life event that may fit your situation and learn more about benefits needs. Then go to www.eHealthInsurance.com to get a quote for an individual insurance plan.

You can't plan for illness or accidents, but the unexpected does happen. That's why going without health insurance, even for a short time, puts you or your family at serious financial risk. So if you're between jobs, or between insurance plans, visit the U.S. Department of Labor's website for information on temporary coverage.

Professional and alumni associations, such as local Chambers of Commerce, may also offer health plans.

If you don't have health insurance, contact your state's Department of Health and Human Services to find out of you qualify for low-income health coverage.

Self-employed or small biz

Small businesses can get group health planhealth plan
A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
information by visiting www.eHealthInsurance.com

Professional and alumni associations, such as local Chambers of Commerce, may also offer group health plans.

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Plan comparison

Review premiumspremiums
The amount charged by a health insurer for a health insurance policy. If you have a health plan thro... more
, co-pays, co-insuranceco-insurance
The portion of the cost of covered medical services paid by the patient under a health plan, after f... more
, etc.

Does your plan fit your medical and financial needs? Managing out-of-pocketout-of-pocket
Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
medical costs will help you control your overall finances. Some options to consider:

  • PremiumsPremiums
    The amount charged by a health insurer for a health insurance policy. If you have a health plan thro... more
    for high-deductiblehigh-deductible
    A set amount that you must pay for your medical services before the health plan starts to pay.... more
    health plans are often lower than for other health plans. Keep in mind, though, that you'll have to pay for your health care out of pocket until you meet your deductibledeductible
    A set amount that you must pay for your medical services before the health plan starts to pay.... more
    and coinsurancecoinsurance
    The portion of the cost of medical services that you pay for, after you first pay any deductible you... more
    kicks in.
  • If your benefits plan has high out-of-pocketout-of-pocket
    Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
    costs, you might consider participating in a Flexible Spending Account or Health Savings Account, if one is available to you.
  • Co-paymentCo-payment
    A set dollar amount or portion that you pay for your medical services. Usually, co-pays start after ... more
    and co-insuranceco-insurance
    The portion of the cost of covered medical services paid by the patient under a health plan, after f... more
    amounts (generally specified dollars or percentages) are out-of-pocketout-of-pocket
    Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
    costs for doctor's visits and medical care that you will be required to contribute. Fees are applied after you have met any applicable plan deductibledeductible
    A set amount that you must pay for your medical services before the health plan starts to pay.... more
    . Co-payments may vary by type of service. Review your plan documentsplan documents
    Plan documents describe the details of a health plan - what services are covered, what services are ... more
    for fee estimates.
  • Use the Health Expense Calculator on PlanforYourHealth.com to estimate annual health care costs.

Choosing the right plan

Does your plan fit your medical and financial needs? Ask yourself:

  • Can I see a specialistspecialist
    A physician who provides medical care in a medical or surgical specialty or subspecialty (for exampl... more
    without a referralreferral
    In some health plans, you must receive a referral from your primary care doctor to see a specialist ... more
    ? Some plans require that you choose a primary care physician (PCP) to coordinate all your care, meaning that you will need a referralreferral
    In some health plans, you must receive a referral from your primary care doctor to see a specialist ... more
    from your PCP before visiting a specialistspecialist
    A physician who provides medical care in a medical or surgical specialty or subspecialty (for exampl... more
    .
  • Will I be limited by the plan's list of preferred or in-networkin-network
    Also called "provider network." A panel of physicians, hospitals and other health care professionals... more
    doctors? Remember, seeking care out-of-networkout-of-network
    Refers to care you receive from doctors and other health care professionals who do not participate i... more
    can increase your >out-of-pocketout-of-pocket
    Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
    costs.
  • What's the total cost of the plan including premiumspremiums
    The amount charged by a health insurer for a health insurance policy. If you have a health plan thro... more
    , co-pays or co-insuranceco-insurance
    The portion of the cost of covered medical services paid by the patient under a health plan, after f... more
    and deductibles?

Don’t underestimate the benefitbenefit
The term "benefit" may refer in general to a health plan (your "benefits"), specifically define the ... more
of wellness

One of the primary functions of your health benefits planhealth benefits plan
A plan purchased by an individual or provided through an employer that provides payment for health c... more
is to keep you healthy. In fact, many plans offer extra incentives to do just that. Check to see if your plan will offer:

  • Coverage for annual check-ups, well-woman and well-child visits
  • Coverage or discounts for exercise programs, smoking-cessation clinics, flu shots and mental health services

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Making your choice

Choosing a plan

Does the plan you're choosing fit your personal medical needs, such as chronic disease man-agement, maternity care, physical therapy, vision, dental care and alternative health care?

  • If you have a chronic disease make sure your plan offers disease managementdisease management
    A program for identifying individuals with a specific illness or disease (usually chronic in nature)... more
    programs.
  • Some plans offer discounts on products and services such as dental and vision care, acu-puncture, health club memberships and nutritional supplements.

FSAs, HSAs – are they right for me?

Health funds (Flexible Spending AccountsFlexible Spending Accounts
A FSA is an account tied to an employer-sponsored health plan. It can be used to pay for medical exp... more
, Health Savings AccountsHealth Savings Accounts
This savings account allows people to pay current health care costs or save for future expenses. To ... more
, Health Reimbursement ArrangementsHealth Reimbursement Arrangements
This is an employer-paid account for employees and retirees. The funds are generally available to pa... more
) are tax-advantaged accounts that can be used to pay for covered medical expenses and out-of-pocketout-of-pocket
Amounts such as copayments and deductibles that an individual is required to contribute toward the c... more
costs.

To be eligible for an HSA, you must be covered by a high-deductiblehigh-deductible
A set amount that you must pay for your medical services before the health plan starts to pay.... more
health planhealth plan
A health plan that you buy or that is provided by your employer. It pays for health care services. I... more
and not be eligible for coverage under any other health plan. Contributions to the HSA can be made by the employer, the employee or both. Contributions are tax deductibledeductible
A set amount that you must pay for your medical services before the health plan starts to pay.... more
and earn interest tax free. The accounts are portable, meaning you can take them with you when you leave your job, and balances accumulate from year to year. HSA funds can be used to pay for qualified medical expenses or withdrawn in cash, although cash withdrawals become taxable and may be subject to an additional withdrawal penalty.

Contributions to an FSA are typically made by the employee, and are free of federal, Social Security and most state taxes. Funds must be used in the year they are accrued; unused funds go back to your employer. Funds are not portable and do not accrue interest

A Health Reimbursement Arrangement (HRA)Health Reimbursement Arrangement (HRA)
This is an employer-paid account for employees and retirees. The funds are generally available to pa... more
is an employer-paid benefitbenefit
The term "benefit" may refer in general to a health plan (your "benefits"), specifically define the ... more
account offered to em-ployees or retirees. HRA funds pay for deductibledeductible
A set amount that you must pay for your medical services before the health plan starts to pay.... more
and co-insuranceco-insurance
The portion of the cost of covered medical services paid by the patient under a health plan, after f... more
amounts, and unused funds in an HRA may be carried over from year to year.

Uninsured options

You can't plan for illness or accidents, but the unexpected does happen. That's why going without health insurance, even for a short time, puts you or your family at serious financial risk. So if you're between jobs, or between insurance plans, visit the U.S. Department of Labor's website for information on temporary coverage.

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