Let’s face it, health insurance can be confusing. Understanding the basics helps you get the most out of your coverage and gives you peace of mind when it comes to something as important as your health. And we’re here to help.
Keep reading for answers to 10 of the most commonly asked member health insurance questions.
1. When does my coverage start?
Some employers have a waiting period before health benefits begin. So the short answer is check with your HR team to find out when your coverage takes effect.
2. How much does it cost?
Your health plan premium is the amount paid each month for your insurance. Your employer usually pays part of the cost, and you pay the rest through payroll deductions. The cost will vary depending on your plan premium and employer contribution.
3. Can I cover my family, too?
Many employers offer family coverage, so you can add a spouse or dependents. Others offer employee-only coverage. Ask your employer what’s available to you.
4. What is a deductible?
A deductible is what you pay for covered health services before your plan starts sharing the costs. For example, if your deductible is $1,000, you’ll pay that amount out of pocket first.
5. What kinds of health plans are offered?
Your employer may offer different plan types:
- HMO (Health Maintenance Organization): You choose a Primary Care Physician (PCP) and need referrals for specialists.
- PPO (Preferred Provider Organization): You can see any doctor, but you’ll usually pay less when you stay in-network.
- HDHP (High-Deductible Health Plan): A plan with a higher deductible but often lower monthly premiums.
- POS (Point-of-Service) plan: A mix of HMO and PPO features — you pick a PCP but can go out of network for care at a higher cost.
6. What’s covered under my plan?
Coverage can vary by plan, but typically includes things like:
- Doctor visits
- Hospital services
- Emergency care
- Prescription drugs (both generic and brand-name)
- Outpatient surgery
- Ambulance services
You’ll also want to review your plan’s out-of-pocket maximum, which is the most you’ll pay in a year for covered services.
7. What are provider networks?
A provider network is the group of doctors, hospitals, and specialists that work with your health plan. You’ll usually save money when you use in-network providers. Depending on your plan, you may have very limited access to providers out of network.
8. Is dental coverage included?
Some employers offer dental insurance in addition to medical coverage. You may have a Dental HMO (DHMO) or Dental PPO plan, each with its own costs and coverage rules. Check with HR to find out if your employee benefits include dental options.
9. What about other types of insurance like disability or life?
Your employer might also offer life insurance, disability coverage, or other supplemental benefits. Ask your employer what’s available to you and how much it costs.
10. Does my health plan include anything besides benefits?
Some health plans, like CaliforniaChoice, include “value-added” benefits like discounts on gym memberships, wellness programs, or virtual care services. Visit calchoice.com to see the discounts and services available to you through your Member Value Suite.
Learn More
Make sure to read all of the materials you receive during open enrollment or when you’re first hired. If you need help with health insurance terms or definitions, check out HeyHealthInsurance.com. It’s a handy online glossary with more than 90 health and insurance terms explained in plain language.