Navigating the Complexities of New Insurance Benefits

Understanding your insurance benefits can feel overwhelming, especially when new plans start each year or when your coverage changes due to a new job or school schedule. Insurance plans often have different effective dates, deductibles, and cost-sharing rules that affect how much you pay and when your benefits kick in. Knowing these details helps you avoid surprises and make the most of your coverage.

How Insurance Plan Years Affect Your Benefits

Not all insurance plans follow the calendar year. Some run on a contract year or plan year that starts and ends on different dates. For example, a plan might begin coverage on March 1 and run through the following February 28. This means your deductible and out-of-pocket maximum reset on that date, not January 1.

Student insurance plans often follow the academic year instead of the calendar year. These plans might start in August or September and end in July. If you have a student plan, knowing the exact start and end dates is crucial to understanding when your coverage is active.

Why this matters: If you visit a healthcare provider before your plan’s effective date, your insurance might not cover the visit. Also, deductibles and benefits reset based on your plan year, so timing your care around these dates can save money.

Changes in Coverage Due to Job or Career Moves

Starting a new job or changing careers often means enrolling in a new insurance plan. Employers typically offer benefits during open enrollment or when you first join the company. This new plan might have different coverage rules, deductibles, and copays.

When you switch plans, your benefits can change in several ways:

• You might have a higher or lower deductible.

• Copays or coinsurance percentages could be different.

• The network of covered providers may change.

• Some services might be covered 100% after meeting the deductible, while others require copays.

  
  

It’s important to review your new plan’s details carefully and ask your HR department or insurance provider for help understanding your coverage.

Understanding Deductibles and How They Affect Your Costs

A deductible is the amount you pay out of pocket before your insurance starts to cover costs. Some plans are self-funded, meaning the employer pays claims directly, which can affect how deductibles work.

If your plan has a deductible, you need to know:

• The total deductible amount (individual or family).

• What services count toward the deductible.

• How your benefits change after meeting the deductible.

  
  

For example, after you meet your deductible, your insurance might cover 100% of therapy sessions, or you might pay a copay ranging from $5 to $60 per visit. Some plans use coinsurance, where the client pays a percentage of the allowed contracted amount.

Family deductibles work differently. Multiple family members can contribute to meeting the total deductible, which can help reduce costs faster.

What Does It Mean When Benefits Change After the Deductible?

Once you meet your deductible, your plan’s cost-sharing usually changes. This can take several forms:

• Copay: A fixed amount you pay per visit or service.

• Coinsurance: A percentage of the allowed charge you pay.

• Full coverage: The insurance pays 100% of the cost.

  
  

These changes depend on your specific plan and the contracted rates your provider has with the insurance company. Some plans cover telehealth visits differently, and certain deductibles may not apply to these services. Some plans have out-of-pocket maximums, which represent the maximum amount a client would pay under their health plan. Once this limit is reached, the insurance company covers 100% of the costs for covered services for the remainder of the plan year.

How to Verify Your Benefits and Contracted Rates

Insurance benefits can be confusing, but you don’t have to figure it out alone. You can:

• Contact your insurance company’s Member Services for detailed benefit information.

• Reach out to your provider’s office to ask about contracted rates and how much you would pay toward your deductible.

• Ask if your plan includes an Employee Assistance Program (EAP), which often covers therapy services at no cost to you.

  
  

Knowing your contracted rates helps you understand your actual costs, especially if you have a deductible or coinsurance.

Tips for Choosing the Right Plan

When selecting a new insurance plan, consider:

• The deductible amount and how quickly you expect to meet it.

• Whether the plan covers your preferred providers and services.

• How copays and coinsurance will affect your out-of-pocket costs.

• The plan’s effective dates and how they align with your healthcare needs.

  
  

Opting for a plan with a lower deductible often results in higher monthly premiums, but you'll pay less when you require medical care. Conversely, plans with higher deductibles typically have lower premiums but require more out-of-pocket expenses before your coverage starts. With a PPO, you can visit out-of-network providers and pay out of pocket, potentially receiving partial reimbursement from your primary insurance if it's not through an in-network provider like Cigna or Aetna.

Reach out to Grounded Connections Counseling to schedule a free 15-minute video consultation or if you need help verifying your Aetna or Cigna benefits,