Consumer profile part 1: needs & requirements

Open Enrollment / By Lance De Peralta / October 7, 2021

Source: "Jim from The Office Stares at the camera" feature photo from

Let me preface this 5-part blog series with a friendly disclaimer:

  • The information presented is intended for general education purposes about health benefits.
  • All terms, concepts, and lessons have been simplified for easy viewing and consumption.
  • Each person’s situation is different. Please talk to your Human Resources department / representative(s), along with the appropriate vendor(s) & insurance broker(s) responsible for offering and administering your company’s health benefits, about your circumstances and available options.


As consumers, we have certain preferences and budgets for the products and services we buy and use.

The same is true with healthcare. So, it’s important you figure out your healthcare consumer profile.

Your profile should include:

  • Health needs
  • Coverage requirements
  • Finances

Healthcare needs

Performing a healthcare needs assessment (HNA) will help you better understand what kind of coverage you should purchase. Simply auto-enrolling in your current plan (assuming it's still offered by your employer) may not be the right choice for you.

Ask yourself:

  • What health services do my family and I need?
  • What medical devices and prescriptions do my family and I need?
  • Are there certain procedures or surgeries that my family and I will need next year?

As you're answering these questions, consider how you used your health insurance this year (and in years past) because it can help you predict your health needs for the following year. Reviewing copies of past bills can be immensely helpful too.

Coverage requirements

The most essential part of your health plan is what it covers. The HNA exercise helps you figure out if a specific plan meets your requirements.

Virtually all health plans cover (to varying degrees) three basic categories of care:

  • Preventive care
  • Urgent care
  • Emergency care

Much of the care that a person receives throughout the year falls into one of these categories, so I’ll discuss them in some detail.

Preventive care

If you've ever had an annual check-up, received a flu shot, or got a screening (e.g., colonoscopy or mammogram) then you've received preventive care (sometimes called routine care). Preventive care is intended to help you stay as healthy as possible.

Regularly scheduled visits and tests allow your doctor to identify any medical problems early-on to "prevent" them from becoming serious (and expensive).

When reviewing your plan options, make sure to check their list of covered preventive care services.

Urgent care

For more immediate or after-hours care, a trip to an urgent care clinic can be a great solution. Unless it’s a true emergency, urgent care is generally a better use of your time and resources. Many urgent care clinics are open seven days a week, have shorter wait times than the emergency room (ER), and staffed with doctors and nurses who have access to x-rays and labs onsite.

Urgent care clinics handle common and non-life-threatening conditions such as:

  • Earaches and infections
  • Minor cuts, sprains and burns
  • Fever and flu symptoms
  • Urinary tract infections (UTI's)
  • Headaches

Emergency care

Unlike an urgent care clinic, the ER is meant for true medical emergencies. The ER is equipped and staffed to handle trauma, x-rays, surgical procedures, and other life-threatening situations such as:

  • Heart attack, chest pain or chest pressure
  • Shortness of breath or severe asthma attack
  • Head injuries
  • Uncontrolled bleeding
  • Severe allergic reactions
  • Severe cuts or burns


Where you receive care - and from whom - are just as important as the actual care itself.

Ask yourself:

  • Who are my current doctors?
  • Did I see any specialists this year?
  • Are there other doctors and specialists that my family and I will need next year?

Each plan has its own network of providers. If you already have doctors and specialists that you like and/or need additional ones, check to make sure they participate in the plan's network. Some plans only offer "in-network" coverage while other plans offer in- and "out-of-network" coverage.

I’ll end it here.

Finances will round out the consumer profile discussion in the fifth and final installment of Open Enrollment – Employee Edition.

Stay tuned!

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