The Importance of Knowing How Your Group Health Insurance Works

How Your Group Health Insurance WorksOver the last several years, thanks in part to the Affordable Care Act (ACA) which was implemented in 2010 by President Obama, health insurance coverage has been at the forefront of conversation, especially when it comes to employer provided coverage. If you have a group health insurance policy, it is very important that you know what health benefits have, how it works and what it may cost you if you do not understand how the policy works.

Many group health insurance plans include allowing policyholders to take free fitness and health classes, join a local gym or even join a support group for illnesses including physical issues as well as mental health issues. If your policy includes this, it is definitely worth taking advantage of.

What You Can Lose By Failing to Know Your Policy

If you have a group insurance policy and don’t fully understand what it covers, or does not cover, you can lose money when you choose to have procedures done without consulting your insurance provider or taking time to carefully read your insurance coverage information in detail. Here are three of the biggest ways you can lose by not knowing the details of your policy:

  1. Choosing a doctor that is not in the insurance providers network is not a good choice unless you like to spend extra money. For example, choosing an in-network physician you will usually pay anywhere from 10% to 20% for a visit. Choosing an out-of-network physician can result in your owing up to 80% or more for the visit.


  1. Many group policies require consumers to obtain a referral for a specialist before they will pay for the visit. For example, if you choose to go to a physical therapist, surgeon or other specialist without your primary physician submitting for approval, you will most likely be stuck with the entire bill to pay on your own as most insurance providers will deny the bill.


  1. If you find that you are billed for services that you feel the insurance company should have paid but you do not file an appeal for payment within the mandatory time limit, you will lose the appeal even if coverage should have paid for the services.


Knowing Your Policy

The best way to avoid those extra fees and hefty charges, it is best to know what kind of policy you have and what, precisely, it covers. For group health insurance, you will most likely have one of the following:


  1. Traditional Indemnity Plan: Also known as a fee for service plan, the consumer will pay everything at the time of the doctor visit and then submit a claim with the insurer for reimbursement. These plans allow the consumer to visit the doctor that they choose to visit.
  1. Health Maintenance Organization (HMO): This is one of the most common group policies and allows members to pay a flat fee to obtain services from doctors, clinics and other healthcare facilities that participate with the insurer. You will need to pay a co-pay per visit with an HMO policy.
  1. Preferred Provider Organization (PPO): When you have a PPO policy, you can usually go to a doctor that has agreed to partner with the insurance company to offer medical services at a lower rate than usual to policy holders. With a PPO, you can choose out-of-network caregivers but will usually pay a little more for services. With in-network providers, the insurance should pay most, and sometimes all, of the bill for your medical services.

No matter where you live in the U.S., understanding your policy and staying in contact with your group policy insurance company is essential when you want to know the most about your policy. Simply knowing that your company offers insurance coverage and choosing to opt in for coverage is not enough to fully protect you when you need to see a physician or have a health crisis or need for treatment. If you fail to really know your policy, you may just find that you are paying more out of pocket expenses than you planned to pay when you signed up for your coverage.