Tips to Help Brokers Aid Employers and Employees in Understanding Group Health Coverage

Tips for understanding coverage

A decade ago, in August 2013, The Washington Post reported that a consumer survey found that just 14% of individuals with private health insurance understood all four basic insurance payment concepts. It found most made their insurance selections based on premium alone.

In 2017, a UnitedHealthcare (UHC) survey found even lower health care literacy. In spite of plan efforts to increase member/patient education, only nine percent of those surveyed understood health plan premium, deductible, out-of-pocket maximum, and coinsurance.

Two-thirds of the UHC survey participants knew “health plan premium” and “health plan deductible.” However, less than half knew the correct definitions of “out-of-pocket maximum” and “coinsurance.”

In 2020, a ValuePenguin survey of 1,000+ participants found 28% who said they had never been confused about their health plan coverage. On the flip side, more than half (57%) said they sometimes avoided treatment because they were uncertain about what their share of the costs might be.

The lack of understanding didn’t stop there. Nearly half of respondents (45%) falsely believe they can switch health insurance plans at any time. The reality is, of course, that they must have a qualifying life event or wait until the next open enrollment period.

On average, more than half (55%) of ValuePenguin survey participants gave wrong answers to the six health questions asked in the survey. Obviously, there’s a lot of misunderstanding about health plans, coverage, and copays. What can you do to help employers and employees?

Education is Key

More resources are available today to help your clients and their employees compare and gain a better understanding of their health insurance coverage. These include printed materials, videos, online tools, and more.

You may want to visit these websites, which offer links to other sites and information of possible interest:

Many carriers – both large and small – offer resources to members and non-members who are interested in information about available coverage. Below are links to nine:

Learning What’s Covered

If an employee in one of your groups wants to know about what’s included in his/her/their plan, a major source of information is the Medical Summary of Benefits & Coverage (SBC). This high-level summary document explains terms used in medical care and health insurance.

Word & Brown offers links to SBCs for many of our carrier partners. Available carriers include:

  • Aetna
  • Anthem Blue Cross
  • Blue Shield of California
  • CaliforniaChoice
  • CalCPA Health
  • Cigna + Oscar
  • Health Net
  • Kaiser Permanente
  • MediExcel Health Plan
  • Sharp Health Plan
  • Sutter Health Plus
  • UnitedHealthcare
  • Western Health Advantage

Also online are links to a Terms Glossary and a “Medical SBC vs. Dental SDBC cheat sheet.” You can easily downloadable these materials online.

2023 Consumer Survey

The Kaiser Family Foundation (KFF) 2023 Survey of Consumer Experiences with Health Insurance interviewed 3,605 U.S. adults to ask about health insurance experiences.

It included questions around how people feel about their coverage, how “affordable” it is, how they interact with their providers, and problems experienced – especially when they are sick.

The interviews were with 978 adults with employer-sponsored coverage (either directly or through a spouse); 885 adults with Medicare; 880 individuals with coverage through an Affordable Care Act (ACA) Marketplace (such as Covered California or Nevada Health Link); and 815 adults with Medicaid. It included those with different levels of income, education, and health status – which could affect their experiences and views on health care.

Among the key findings was that most adults gave positive ratings to their health insurance. Eighty-one percent gave an overall “excellent” or “good” rating, although ratings did vary based on health status. Of those describing their health status as “good” or better, 84% rated their insurance positively. That compares to 68% of those saying their health is “fair” or “poor.”

Most (58%) of insured individuals reported some sort of problem using their insurance during the prior 12 months. That includes claim denials, provider network issues, and problems with needed pre-authorization.

Among those with insurance problems, 17% said they could not receive care as recommended, 15% said they had a decline in their health, and 28% said they paid more than expected because of their problem.

Beyond out-of-pocket cost concerns, premium affordability is an issue. Nearly half (46%) of those with employer-sponsored insurance and more than half (55%) with Marketplace coverage rate their insurance negatively as it relates to premiums.

About nine in 10 in the 2023 KFF survey said they support requirements that insurers maintain current, accurate provider directories, furnish easier-to-read Explanations of Benefits, disclose denial rates to regulators and the public, and provide – in advance if requested – information about whether care is covered and the potential out-of-pocket liability.

We’re Here to Help You

Your job as an insurance broker is not always easy. But your efforts to help your clients and their employees are appreciated. Make sure you discuss with them how you’re available to answer questions and facilitate service-related matters, if needed.

Talk with your Word & Brown representative about what we can do to help you. We are committed to offering you a range of tools and resources to help you quote more, write more, and retain more business – year after year. If you’re not already doing business with us, contact us at 1-800-869-6989 or fill out our online form to get started.

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