January 12, 2026

What Employees Struggle with Most and How Employers Can Help

With the start of a new year comes fresh routines, new goals, and for many employees, new health insurance plans or benefits that have reset. Deductibles start over, out-of-pocket maximums return to zero, and plan details may look different than they did just weeks ago. While these changes are expected, they can also create uncertainty for employees who are still trying to understand how their coverage works.

For many employees, health insurance already feels like a foreign language. Even those who use their benefits regularly often admit they don’t fully understand how their plan works until they’re faced with a claim, a bill, or an unexpected out-of-pocket cost. That’s why the beginning of the year is an ideal time for employers to reinforce benefit education and help employees build confidence in using their new or newly reset coverage.

The good news is that this challenge isn’t insurmountable. By understanding where employees struggle most, and taking a proactive approach to education, plan design, and support, employers can dramatically improve engagement and the overall benefits experience.

Where Employees Get Stuck

Despite open enrollment meetings, benefit guides, and plan summaries, certain health insurance concepts consistently cause confusion.

1. Deductibles vs. Out-of-Pocket Maximums

Many employees assume their deductible is the most they’ll ever pay in a year. In reality, deductibles and out-of-pocket maximums serve different purposes and misunderstanding the difference can lead to unpleasant surprises.

Employees often struggle to understand:

• What expenses apply to the deductible
• When coinsurance begins
• How the out-of-pocket maximum protects them financially

2. In-Network vs. Out-of-Network Care

Networks remain one of the most misunderstood elements of a health plan. Employees may not realize:

• A provider can be in-network at one location but not another
• Out-of-network care can still be covered but at a much higher cost
• Balance billing may apply when using out-of-network providers

These gaps in understanding frequently show up as unexpected bills after care has already been received.

3. Copays, Coinsurance, and “What Will This Cost Me?”

Even when benefits are clearly outlined, employees often struggle to estimate what they’ll actually pay for care.

Common pain points include:

• The difference between a flat copay and percentage-based coinsurance
• How services like imaging, outpatient procedures, or specialty visits are billed
• Why costs can vary so widely for the same service

Without clarity, employees may delay care or be shocked when the bill arrives.

4. Explanation of Benefits (EOBs)

An Explanation of Benefits is not a bill, but many employees don’t realize that.

EOBs often raise questions such as:

• Why does this amount look so high?
• What do I actually owe?
• Did my insurance deny something?

Without guidance, employees may ignore EOBs altogether or assume something has gone wrong.

How Employers Can Help

Improving health insurance literacy doesn’t require overwhelming employees with more information. It requires the right information, delivered at the right time, in the right way.

1. Simplify the Message

Clear, plain-language explanations go a long way. Employers should focus on:

• Real-world examples instead of technical definitions
• Visual tools and comparisons
• Bite-sized education throughout the year, not just during open enrollment

2. Design Plans With the Employee Experience in Mind

When employees don’t understand their health benefits, the impact goes beyond confusion. Employers may see:

• Lower benefit satisfaction scores
• Delayed or avoided care
• Increased frustration directed at HR teams
• Missed opportunities to use cost-saving programs and resources

Simply put, benefits are more effective when employees know how to use them.

Thoughtful plan design can reduce confusion before it starts. This may include:

• Clear distinctions between tiers of care
• Transparent cost-sharing structures
• Incentives that encourage preventive and in-network care

When plans are intuitive, employees are more likely to engage confidently.

3. Leverage Your TPA as a Partner

A strong third-party administrator does more than process claims.

TPA support can include:

• Member advocacy and live support when questions arise
• Nurse and clinical outreach to guide members through complex care
• Proactive education based on real utilization and claims data

Having experts available helps employees feel supported—and helps employers avoid becoming the default help desk.

The Bottom Line

Employees don’t need to become health insurance experts but they do need to understand enough to make informed decisions about their care.

When employers prioritize education, thoughtful plan design, and meaningful TPA support, employees are more engaged, more satisfied, and better equipped to use their benefits effectively.

At Nova, we believe informed members make stronger health plans. By helping employees navigate everything from deductibles to networks, employers can turn confusion into clarity and benefits into a true value-add. Need more support? Check out our Glossary of Common Health Insurance Terms.