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Health Plan FAQs: Top questions employees have

HR frequently receives health plan questions from employees. Healthgram’s customer service team provides a helpful resource.

It’s not uncommon for employees to have questions about their health plan. In fact, a Harris poll found that two in five insured Americans did not have a good understanding of the services actually covered under their healthcare plans.

To help, our customer service team has answered the top eight questions employees have about their health plans, so you can clearly explain them to your employees.

For more helpful employee communication tips, access our 2018 open enrollment guide.


1. What’s covered under my health plan?

The Summary of Benefits Coverage summarizes the key features of the plan (or plans) that are offered. This document details the benefits covered under the plan, including what employees can expect to pay for services, coverage limitations and exceptions.

Find the Summary of Benefits template here. Basic plan information is covered in a question and answer format on page one, while coverage for common medical events is detailed on pages two and three. Employees may also find it helpful to review the coverage examples on page five. You may reference all regulations and guidelines regarding the Summary of Benefits here.

If you have questions regarding your Summary of Benefits, your health plan administrator should be able to provide you with a copy and review the plan with you. Healthgram members may access their Summary of Benefits through their Member Portal and ask any questions through the online customer service tool or by phone.

Looking to help employees define common terms in their SBC? Try our guide to the 10 must-know health insurance terms.


2. Are there ways I can save on healthcare expenses?

Ensure your employees understand their plan is the key to managing health care expenses. You can share the following four tips with your employees to help them become more informed healthcare consumers and help them save on healthcare spend.

  • Use an in-network provider for any medical treatment you receive.
  • Compare costs of procedures before seeking care. The cost for the same health care service can vary by 200 to 500 percent depending on where care is sough. If you’re a Healthgram member, contact your Advisor for guidance. Other sites such as Healthcare Bluebook are a great place to start.
  • Know your prescriptions. If your prescription has been on the market for a while, often times there is a generic version that has the same active ingredients but on average can cost 80 to 85 percent lower than the brand-name product. Always ask your doctor if a generic is available for the drugs you are prescribed.
  • Know where to go when you need care. You can curb your health care spending by avoiding the most expensive kinds of care, such as emergency care, when possible. Unless you are facing a life-threatening problem such as chest pain or major trauma, you may be able to seek care at an urgent care facility or by making an appointment with your Primary Care Doctor.

For more ways to involve employees, view “How to help employees manage rising healthcare costs”.


3. How long are dependent children allowed coverage under a health plan?

Dependent children are typically allowed under the plan until they turn 26 years old, but plans can vary. Check with your Summary of Benefits Coverage for the most accurate information.


4. Once I am enrolled in a health plan, can I make changes to it?

If an employee would like to make any changes to their plan it needs to be completed during your company’s open enrollment period. These changes may include adding or removing dependents (spouse, children) or changing the plan they are currently enrolled in if your company offers more than one plan option. Outside of Open Enrollment, however, changes are only allowed when there is a Qualifying Life Event.


5. What is considered a Qualifying Life Event?

According to, a Qualifying Life Event includes the loss of existing health coverage including job-based, individual, and student plans, losing eligibility for Medicare, Medicaid, or CHIP, and turning 26 and losing coverage through a parent’s plan. Household changes, such as getting married or divorced, having a baby or adopting a child or experiencing a death in the family, also count as qualifying events. To know exactly which qualifying events are included in your plan, review your plan document.


6. What is the difference between an in-network and out of network provider?

Your health plan administrator has partnered with specific networks to provide you with doctors, facilities and providers that would be considered in-network. The specific network has negotiated discounts with this group of medical professionals, so charges in-network should always be lower than those out-of-network.

Out-of-network providers can end up being significantly more expensive and your employees may be responsible for the full amount charged for that visit. We recommend encouraging your employees to only seek care at in-network provides to save on healthcare expenses. It’s helpful if employees can search for in-network providers using an online or mobile resource.


7. How will I know when to use the ER, go to Urgent Care or make an appointment with my PCP?

Employees should always go to the ER for emergency situations, like a suspected heart attack or a broken bone. For non-life threatening health conditions, a trip to urgent care is usually more cost-effective, as there is a significant cost difference between the emergency room and urgent care.

If the problem occurs during their primary care doctor’s regular office hours, they can call first and make sure they’re headed to the right place. Sometimes a primary care doctor can squeeze patients in on the same day.


Open enrollment is a great time to address employee questions and inspire engagement. Access seven more tips from our account management team in our 2018 open enrollment guide.


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