Reference Guide
Purchasing Coverage
Plan Value: Balancing Benefits and Costs
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Tips
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Health insurance products are complicated, and growing more so. When shopping for plans, you’ll want to look carefully at coverage for the services your employees will use most, such as office visits and prescription drugs. Even though it’s used less frequently, coverage for hospitalization is also critical.
In addition to these basics, below we list some specific benefit categories that may be worth a careful review. Depending on your employees’ circumstances, some or all of these may make a big difference for your business.
- The specific structure of the pharmacy benefit. Coverage may involve different levels of payment depending on whether drugs are generic or brand name, and whether they are included in the health plan’s formulary.
- Behavioral health coverage. California’s mental health parity law (AB88) requires that care for certain severe mental health diagnoses and childhood emotional disturbances be provided at the same member cost as medical care. As a result, information about behavioral health coverage can be confusing, because coverage differs depending on whether or not the diagnosis is included in the AB88 list.
- Annual out-of-pocket maximum. If the consumer reaches the out-of-pocket maximum, the health plan waives out-of-pocket charges for the remainder of the year. Lately these maximums have been rising. Though it’s unlikely that any of your employees will reach this level, it can bring peace of mind to know that no matter what unforeseen needs emerge, there is a limit to how much a particular individual or family will have to pay if you choose a plan with lots of cost-sharing features.
Other documents in the Purchasing Coverage section:
- Brokers
- Budgeting and Cash Flow
- Employee Census
- Evaluating Health Coverage
- Evaluating Insurers and Health Plans
- Plan Contract and Implementation
- Plan Value: Balancing Benefits and Costs
- Preparing to Purchase Group Coverage
- Purchasing Alliances
- Purchasing Strategies
- Purchasing Without a Broker
- Trade Associations
- Health Insurance Exchanges
- Which Payroll Records Do I Need?
