How to Understand Your Health Insurance and Improve Your Healthcare Experience

How to Understand Your Health Insurance and Improve Your Healthcare Experience

Healthcare experiences aren’t typically enjoyable. You seek out healthcare treatment when you’re ill or injured and leave the doctor’s office with a hefty bill to pay later. Thankfully, health insurance is available to alleviate healthcare costs and make it easier for you to navigate the healthcare experience. You probably receive health insurance from your employer, or your spouse’s employer, as part of their employee benefits program but are often confused when the time comes to utilize it. The following tips will give you a better understanding of your health insurance and help improve your healthcare experience.

Understanding Health Insurance Terms

  • What is a deductible? As you incur expenses, the insurance company keeps track of them as they accumulate towards your deductible. Typically, this is for major services, such as inpatient and outpatient hospital services, home healthcare, major diagnostics, etc.
  • Where does the copayment come into play? With most major medical plans in the market today, you will have a specified copayment for office visits, lab and x-ray, pharmacy, emergency room visits, and some urgent care services. When the copayment is listed, that is all you pay, and your deductible does not apply.
  • What is the out-of-pocket maximum? The total amount a covered person must pay before his or her benefits are covered at 100%. The out-of-pocket maximum does include deductibles and copays.
  • What is a Section 125 Plan? Section 125 of the IRS code allows you to pay your share of the health, dental, and certain other health premiums with “pre-tax” income. That means your employer takes the premium out of your paycheck before you pay taxes on it. You save money because you do not pay taxes on the money used to pay for the insurance.
  • What is a Qualifying Event? Under the IRS Code Section 125, you cannot make changes to your elections unless you have a qualifying event such as a birth, marriage, divorce, death, or some other event that would allow you to make changes during the year. If you do not have a qualifying event occur, you can only make changes at annual open enrollment.

Navigating Visits to the Doctor’s Office

  • Find a primary care physician you can trust before any health concerns arise.
  • Make a list of how, what, when, and where your symptoms began.
  • Make a list of current medications you are on.
  • Make sure you have up-to-date documentation – a medical ID card with your carrier name, policy number, claims addressed, copay or deductible amounts and your member ID (remember you can get temporary cards online at your carrier’s website).
  • If you are there for a routine physical exam, remind your physician to file it as a routine preventive care coding.
  • Contact your insurance company if you believe your claim was paid incorrectly.
  • If you are concerned about your diagnosis or not sure about a prescription, check with your employer to see if you have an advocacy program available to help answer questions and make sound decisions.
  • When communicating with your provider or insurance carrier, make sure to keep a record of the communication, including the name of the person you spoke with and the date and time of the conversation, and remember to get a reference number if one is available.

Saving On Costs and Time

If you are suffering from minor illnesses or injuries, go to a convenience clinic located in your local pharmacies, such as CVS or Walgreens, or other drug stores. These clinics will charge you an office visit copay and will have your prescription ready shortly after you check out with the provider. This will not only save you money, but it will also save you time. Urgent care and emergency room visits are very expensive and wait times are enormous.

Check with your local pharmacy providers to see if they have free or low-cost prescriptions available. In Florida, Publix provides most oral antibiotics free of charge as well as some maintenance medications. Some pharmacies will provide you with a 90-day supply of a drug right there at the location and charge you a lower fee than what you would pay under your health plan. Remember, you don’t have to use your insurance program if the pharmacy costs are less. Ask the pharmacist if it is better to use or not to use your insurance. There are also many pharmacy discount programs available.

Remember these tips next time you need to visit the doctor’s office and utilize your health insurance. If you’re confused about any steps along the way, contact your employer or insurance provider for assistance. If you’re not satisfied with your current health insurance plan, offer suggestions to your employer long before open enrollment approaches.


A BKS Employee Benefits Advisor can help your employer assemble the best employee benefits plan for you and your colleagues.

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This document is intended for general information purposes only and should not be construed as advice or opinions on any specific facts or circumstances. The content of this document is made available on an “as is” basis, without warranty of any kind. Baldwin Risk Partners, LLC (“BRP”), its affiliates, and subsidiaries do not guarantee that this information is, or can be relied on for, compliance with any law or regulation, assurance against preventable losses, or freedom from legal liability. This publication is not intended to be legal, underwriting, or any other type of professional advice. BRP does not guarantee any particular outcome and makes no commitment to update any information herein or remove any items that are no longer accurate or complete. Furthermore, BRP does not assume any liability to any person or organization for loss or damage caused by or resulting from any reliance placed on that content. Persons requiring advice should always consult an independent adviser.

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