Maximizing Benefits: How Informed Decisions Shape Healthcare
Key Highlights
- Understanding common health insurance processes helps people make informed healthcare decisions, such as annual open enrollment.
- Explanation of benefits (EOB) documents explain claims, insurer payments, and member costs, and they should be reviewed carefully.
- Verifying coverage before care takes place helps people understand networks, benefits, and expected costs, supporting more informed healthcare and budgeting decisions.
Making the most of health insurance benefits means understanding processes and documents that apply to everyone and, at the same time, are specific to each individual. From open enrollment to explanations of benefits, knowing how these pieces fit together helps people make more informed healthcare decisions.
Open Enrollment Allows People to Compare and Update Coverage
Every year, there’s a period of time known as open enrollment when people can choose to keep or change their health insurance plan. Missing this window means an individual must generally stay with their current plan unless a life event such as marriage or divorce, the birth of a child, or moving to a different ZIP code qualifies them for a “special” enrollment period.
What Is Open Enrollment?
During open enrollment, people can sign up for a health plan or make changes to their existing coverage. They can compare the cost of premiums and deductibles, review whether care provider networks have changed, evaluate prescription drug coverage options, and consider other features to ensure the plan they select meets their needs.
When Is Open Enrollment?
Open enrollment timing depends on the type of coverage and where a person lives. Employer-sponsored health insurance plans typically hold an open enrollment period for two weeks in October or November each year. The timing varies by employer. The health insurance marketplaces created by the Affordable Care Act hold open enrollment from November through January.
What Is an EOB?
An insurance claim is a request for payment. An explanation of benefits, or EOB, explains that claim to the health plan member and summarizes the care delivered. Along with information detailing the care provider’s charges, the insurer’s payment, and the member’s financial responsibility, it usually includes the service date, the provider or facility involved, and the services received. It shows the cost for services that has been negotiated for the care provider to charge within that person’s health plan. An EOB is not a bill.
For example, the EOB will show whether the care was provided in a doctor’s office, a hospital, or an emergency department. It displays whether the care was a preventive exam, a health screening such as a mammogram, or a CT scan. It may show that a care provider’s standard rate for a service is $300, but that the member’s health plan negotiated a discount that lowers the rate to $250. The EOB then might show that the insurer paid $225, and that the member is responsible for the remaining $25 through a copay.
An EOB can also detail a member’s progress toward meeting their deductible and out-of-pocket maximum.
Why an EOB Should Be Carefully Reviewed
An EOB deserves a careful read because catching errors can make it easier to resolve billing questions later. Discrepancies to watch for include:
- Incorrect service dates
- Duplicate charges
- Services that were never received
- Out-of-network cost sharing applied to an in-network visit (for example, the physician who performed the service was in the health plan’s contracted network and care should be covered, but the EOB shows the care was not covered)
- Coding, which explains what service was provided, or billing details that do not match the care provided
Why Verifying Health Insurance Coverage is Helpful
Health insurance benefits should be verified even before making appointments. This allows the individual to better understand their options, including where to get care, whether a care provider is in their health plan’s network, and the costs that may be involved. Health plans make coverage details available through a variety of channels, such as member websites, apps, phone lines and 24/7 chat options.
“Knowing what your health plan covers before you receive care can help make healthcare easier to navigate,” said Robert Bunch, president, Commercial East Region and Specialty Business for Elevance Health. “When people understand their options and what their costs may be, they are better equipped to make decisions that support both their health and their budget.”
Medicaid Coverage Must Be Renewed Regularly
The individual states that offer Medicaid plans use a renewal process to determine whether an individual or household can continue to be covered. In some cases, a state can renew eligibility automatically using available data. In other cases, additional information is required and a renewal form must be completed.
“Keeping mailing addresses, phone numbers, and email information current with the state is a really important part of maintaining coverage,” said Aimee Dailey, president of government health benefits at Elevance Health. “Too often, people lose their coverage simply because a state agency did not receive the needed documentation in time.”
Informed Decisions Help Turn Coverage Into Better Access
Health insurance benefits work even better when people understand and use them effectively. Open enrollment, EOB review, and coverage verification together shape whether people have coverage, where and how they obtain care, what that care costs, and whether their coverage continues. When these aspects are better understood, health insurance benefits can fully support people in the way they were intended. That support means helping people get higher-quality care, with the best experience at the lowest possible cost.
Frequently Asked Questions
What is open enrollment in health insurance?
Open enrollment is a period of time each year when people can sign up for or change their health insurance plan.
What is an explanation of benefits?
An insurance claim is a request for payment. An explanation of benefits further describes that claim to the health plan member and summarizes the care delivered. It lists financial responsibilities but is not a bill.
Why is it important to verify health insurance coverage?
It is important to verify health insurance benefits before someone receives care, because this allows the individual to better understand their options, including where to get care, whether a care provider is in their health plan’s network, and the costs that may be involved.
How does Medicaid renewal work?
Medicaid renewal uses a process to determine whether an individual or household can continue to be covered. In the individual states that offer Medicaid plans, some renewals are automatic, while others require updated information or a completed form.
How can health insurance benefits be maximized?
Health insurance benefits can be maximized by reviewing plan options during open enrollment, confirming coverage before care, understanding EOBs, and completing renewal steps on time.