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Tips for effectively using health coverage

As of the end of January 2014, around 3.3 million people purchased health insurance on the Marketplace. Having health coverage is great! Health insurance provides many essential benefits and limits out of pocket medical costs for the insured. However, insurance is incredibly complicated. Even people who’ve been insured for their entire lives can be confused about language and how to get the biggest bang for the buck.

Here are a few tips to help you understand how to use your health coverage:

Have your membership card with you at all times. If you need emergency care, this will save you hassle and may help stem billing problems.

Understand which doctors and hospitals are in your plan’s network. This is very important since each plan may have a different network (even between plans offered by the same insurance company). Care will cost significantly more for out-of-network providers. It’s best to be prepared by checking your insurer’s website for their network list.

* Know this: If you go out of network, your out-of-pocket maximum does not apply.The health law caps out-of-pocket maximums for qualified health plans at $6,350 for individuals and $12,700 for families in 2014. That’s a lot of money, but at least it’s a cap. It’s best to try to stay in-network (even for emergency care) whenever feasible.

Except for actual emergencies, avoid the emergency room! Co-pays to visit the ER differ from those required for a routine doctor’s office visit. Many of those ER co-pays are in the hundreds of dollars. It will, of course, be up to the insured to determine what qualifies as an emergency. Urgent care centers, which are popping up across the US, might be good, lower-cost alternatives for some health issues.

Pay your premium on time. Even though most insurers will offer a brief grace period, don’t delay. If you purchased a Marketplace plan (especially with a subsidy), and if that plan is cancelled mid-year due to non-payment, you won’t have another chance to purchase with a subsidy until the next open enrollment period. 2014 open enrollment ends March 31, and 2015 open enrollment (for 1/1/15 coverage) begins November 15, 2014.

Use all of the tools offered by your insurer. That includes online billing, cost tracking, network lists, and referral systems. You might save money, be better able to catch possible billing errors, and learn how to reach customer service staff.  Many insurers are also making transparency tools available, so that their members can know more about the quality and pricing of their docs and hospitals.

Understand your plan’s summary of benefits and coverage. Insurers might refer to this document as your “SBC”. As the title implies, this document provides an overview of your coverage and the costs associated with care. It can be confusing (even dumbfounding), but read it anyway. If you need help understanding what it means, ask someone. Your insurer’s customer service staff are available, as is your health insurance agent (if you used one). Alternatively, MI Health Answers might be able to help out– always feel free to post your questions in our Community section!

Have questions?  Post them at, or email them to

This post was contributed by Shannon Saksewski (Health Education Program Manager, Detroit Regional Chamber).  Shannon can be contacted at