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Delivering on the Good Hands

Understanding your health benefits

It's important to take the time to make sure you understand how your plan works before you start using health care services. Doing so may save you a lot of money.

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Did you know
In 2020, 67% of U.S. workers were covered by a self-funded health plan?1

Where should I go for care?

One of the most important things to consider is where to seek care. You have more choices than ever when deciding where to go for medical care, and choosing wisely can help you save money. Here are some things to keep in mind:

  • Does your health plan use a provider network? If so, choosing a doctor and facility that is in network will save money.
  • Emergency rooms (ERs) are typically the most expensive places to get care. You should only use an ER in cases of severe or life-threatening conditions2.
  • Telemedicine services, such as Teladoc®, offer convenience and the most cost savings. If your health plan includes telemedicine services, this is a good option to treat cold and flu symptoms, ear infections, headaches, cuts with controlled bleeding, and behavioral health issues such as depression, anxiety, and stress.
  • Your primary care provider's office is also a good choice for treatment and often costs less than retail health clinics or urgent care centers.

What does this mean?

Here are some common terms you may hear when learning about your employee benefits coverage through Allstate Benefits:

Advantage Plan – This is a type of medical plan that will only pay benefits if members see a healthcare provider within a specific network. Out-of-network services will only be covered for Emergency Services. The benefit of this type of plan is lower health care costs.

Coinsurance – The portion of medical expenses that the covered person is responsible for paying after the deductible is met. Often, this is a percentage. For example, if a policy includes 20% coinsurance, the covered person is responsible for paying 20% of the medical expenses and the health care plan will pay the remaining amount.

Copayment – A copayment is the portion of medical expenses that the covered person is responsible for paying. Often, this is a specified dollar amount. For example, if a policy includes a $20 copay, that is what the covered person will pay the provider at the time of service and the health care plan will pay the remaining amount.

Deductible – This is an amount paid out of pocket by the covered person before a health plan pays any expenses. For example, if a health plan has a $1,000 annual deductible, the covered person must pay all medical expenses up to the first $1,000 each year before their plan benefits kick in.

Network – This is a group of doctors, hospitals, clinics and other health care providers and facilities that have a contract with a health insurance carrier to provide care at a discounted rate. These providers meet specific quality standards required by the health plan.

Network Only Plan – See Advantage Plan.

PPO – A PPO, or Preferred Provider Organization, is a type of medical plan that allows members to see any health care provider they choose. However, the PPO plan will pay a larger portion of the bill if the member sees a provider in their network. The benefit of this type of plan is a wider choice of providers.

Premium – This is the amount of money that is paid to the health plan for the policy. With group health plans, employers typically pay for some of the premium costs and the remainder of the premium is taken out of the employee's paycheck each month.

Retail Clinic – An outpatient clinic located within a retail, grocery or drug store. These clinics typically treat minor illnesses and injuries and provide preventive care such as vaccinations.

Telemedicine – A visit with a health care provider that is conducted through telecommunications technology, such as a computer or mobile phone app.

Urgent Care Center – A walk-in clinic that primarily treats injuries or illnesses that require immediate care but are not serious enough for an emergency room visit. They often are open extended hours when primary care clinics may be closed.

How does a health plan work?

The following examples illustrate how a health insurance plan may work.3 Keep in mind that each health plan is different. Take into consideration whether you have a network, deductible or copayment.

Gail's broken leg

Gail is a member of her company's group health plan. Gail falls off a ladder while painting her shed and fractures her leg. Gail's insurance plan has a network, so she goes to an in-network emergency room for care. Her insurance company is billed a total of $3,000.

  • Deductible: Gail's health plan includes a $1,000 deductible. Gail received treatment for another health issue earlier in the year and has already paid $200 of her deductible. This means she is responsible to pay the first $800 of the bill in order to meet her annual deductible amount.
  • Coinsurance: After the deductible has been met, Gail has 20% coinsurance. There is still $2,200 left to pay on the claim, so Gail is responsible for 20% of that amount, or $440.
  • Insurance plan: Gail's insurance plan pays the remaining $1,760.

Dustin's ear infection

Dustin is a 3-year-old boy who is experiencing ear pain and a low-grade fever in the middle of the night. His father is a member of his company's group copay health plan, and has selected coverage for everyone in his family. Because their health plan includes Teladoc telemedicine services, Dustin's mother decides to use her laptop to request a consultation with a health care provider. The provider diagnoses an ear infection and prescribes an antibiotic, which can be picked up at a local 24-hour pharmacy. Although there is no charge to Dustin's parents for the Teladoc visit, his parents are responsible for paying a $10 copayment for the medication.

Disclaimers and notes

All exclusions and limitations apply to any coverage issued, including pre-existing condition limitation, if applicable.

1Source: https://www.statista.com/statistics/985324/self-funded-health-insurance-covered-workers

2You may be required to pay a penalty for using emergency room services in non-emergency situations.

3The examples are intended for illustrative purposes only and are not meant to reflect your specific situation. Costs, health care coverage and health care situations may vary.

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