As the year winds down, you have an opportunity to remind your employees about an important benefits deadline. For health plans with calendar-year deductibles and out-of-pocket maximums, these spending totals generally reset on January 1.
Employees who have already met these thresholds may benefit from scheduling appropriate, covered care before December 31. A timely reminder can help your team understand their benefits and avoid unexpected expenses.
Explain What Starts Over
A deductible is the amount a member pays for certain covered services before the plan begins sharing those costs. After meeting the deductible, copays or coinsurance may still apply.
The out-of-pocket maximum limits what members pay for covered, in-network care during the applicable year. Once reached, the plan generally pays the full allowed cost of covered, in-network services for the remainder of that year. Premiums and non-covered services do not count toward this limit.
When these totals reset, employees will begin accumulating eligible expenses again. Confirm your plan’s reset date before sending reminders, since some plans follow a different schedule.
Encourage Thoughtful Year-End Planning
Deductibles and out-of-pocket maximums are not use-it-or-lose-it accounts. However, the financial advantage of having met them generally does not carry into the next year.
Employees who have satisfied their deductible may pay less for additional covered care before the reset. Those who have reached their out-of-pocket maximum may have no additional cost sharing for eligible services.
Encourage your employees to discuss timing with their healthcare providers for recommended follow-up visits, diagnostic testing, therapy, or planned procedures. They should never pursue unnecessary treatment or delay urgent care because of an insurance deadline.
Remind Employees to Check the Details
Before scheduling, employees should review their insurer’s member portal or contact customer service to confirm their accumulated spending.
They should also verify provider networks, coverage, referrals, and prior authorization requirements. Meeting a deductible does not make every service covered, and an authorization does not necessarily eliminate cost sharing.
Appointments can fill quickly near year-end, so early planning helps. Employees should confirm how the plan assigns expenses to the year, especially for treatment spanning December and January.
Make Benefits Communication Easy
Send a brief reminder through email, payroll communications, or your employee benefits portal. Include instructions for finding plan information and encourage employees to contact the insurer privately about personal claims.
Contact our group insurance brokers for help explaining your plan’s reset rules and preparing employee reminders. We can help your team use their coverage wisely before the new year begins.
