Individual & Family Coverage
Group Health Insurance
Group health insurance is typically offered by employers. Or, if you are a member of a union, professional association, or other group, you may be able to get group coverage through that organization.
When group health insurance is an employee benefit, your employer usually pays a portion or all of the premiums. This means your costs for health insurance premiums will be lower than they would be if you paid the entire premium alone.
When you get group insurance through membership in an organization, you usually will benefit from being a member of a large group. You may pay less for premiums than an individual would pay. However, the organization often does not pay a share of the premium, meaning you may be responsible for paying the entire premium yourself.
Comparing Plans
Some employers allow employees to choose between several plans, including both indemnity insurance and managed care. Other employers offer only one plan. Some group plans offer dental and/or vision benefits as well as medical benefits. So it is important to compare plans to find the one that offers the benefits you need most. Once you enroll in a health insurance plan, you usually cannot change to another plan until the next open season, usually set once a year.
It is important to make the best possible choices for you and any covered family members. Be sure to compare:
- Access to doctors, hospitals, and other providers.
- Access to after hours and emergency care.
- Out-of-pocket costs (coinsurance, copays, and deductibles).
- Exclusions and limitations.
- Annual out-of-pocket maximums.
- Lifetime payout maximums.
Even if you do not get to choose your health plan—for example, if your employer offers only one plan-you still need to understand your coverage.
- What kind of services are covered by the plan?
- What steps do you need to take to get the care you and your family members need?
- When do you need prior approval to ensure coverage for care (for example, elective hospitalization for scheduled surgery)?
- How are benefits paid; do you have to submit a claim?
If you are choosing between indemnity and managed care plans, remember that they may differ in several important ways, including:
- How you obtain specialty care.
- How much and sometimes how you pay for care.
The major difference between indemnity (non-network based coverage) and managed care plans (network-based coverage) concerns choice of doctors, hospitals, and other providers; out-of-pocket costs for covered services; and how bills are paid.
Tips for Choosing Plans
Think carefully about what is important to you.
Don't wait until you need emergency care to ask questions. Ask plenty of questions before you choose the plan.
If you have a choice of plans, compare them side by side for services covered, how much the insurance plan will pay, and which physicians and hospitals are included in the plan.
If you are choosing between a traditional (indemnity) plan and a managed care plan, make sure you understand the difference in services and any pre-authorization requirements.
Even if you do not have a choice of plans, make sure you understand your coverage.
Remember, plans vary in what they pay. No plan will pay 100 percent of your medical expenses, but some plans will pay more than others.
