Using Health Insurance

How to use health insurance

Health insurance helps pay for health care. It helps cover services ranging from doctor visits to major medical expenses related to illness or injury.

You have to know how to use health insurance effectively to get the best care at the lowest cost.

• This means more than learning insurance terms like copay and deductible.

• It means understanding your insurance plan's rules.

• Getting care at the right time and in the right place.

• Using your plan's network of providers to keep costs down.

• Using insurance for routine health care and prevention, to avoid more serious health problems.

Health insurance is confusing and complex. Becoming more knowledgeable can help you choose the right plan with the best coverage, save money and, most of all, keep you in the best of health.

Stay healthy

Staying healthy should be everyone's number one priority. Unfortunately, too many people avoid seeing the doctor because they're worried about the cost.

♦ The Affordable Care Act established new requirements for insurance companies.

Now an annual physical must be covered at no cost. This is a benefit everyone should take advantage of.

Staying healthy takes some effort, like getting regular checkups. Checkups are a way to catch problems before they get worse, and to help manage problems you may already have.

• Ask yourself: when was the last time you had a physical or wellness check?

If you can't remember, you're overdue. You need to get moving.

Don't wait until you're really feeling ill. Try to get this out of the way in the first part of the year.

Where to start?

Understand your health insurance

Every health insurance plan is different, so it's important to check your plan to see what it covers and what it expects you to pay. Your plan must provide an outline of what it covers.

This outline is called a Summary of Benefits and Coverage (SBC). It's a brief written description of services and the costs you're expected to share.

The SBC is usually very brief and doesn't go into much detail. A plan's details can be found in a document called a Benefits Booklet. It goes into detail about how the plan will handle various situations.

• X-rays taken during an office visit are usually covered under the office copay, while X-rays done at an outpatient facility may cost much more.

The SBC is a good start. Your insurance company usually sends it in the mail. If you don't have this summary, you need to get it.

• Most insurance companies also provide this information on their websites. Major insurance companies offer a number of plans, so be careful to find information on your particular plan.

If you're not certain, don't hesitate to call your plan's customer service number, located on the back of your insurance card.

• As you use your health insurance more, you'll want to consult your plan's Benefits Booklet more than the SBC, so it's good to have a copy.

♦ Some preventive benefits are required by the Affordable Care Act.

Annual wellness visits are one such benefit. Make use of it.

This benefit is supposed to entitle you to a free (no cost) annual physical with a primary care doctor.

• Not all bloodwork is free. Certain screenings, like cholesterol and diabetes tests, are covered. But other routine blood panels your doctor orders may be billed to your deductible. Ask before the blood is drawn.

• On Medicare? Medicare's free "Annual Wellness Visit" is a planning visit, not a full physical. If the doctor does a physical exam or treats a problem during the visit, you may get a bill.

Some words of caution, though: everything may not be free.

♦ Many medical practices are coming up with creative ways to tack on extra charges to the annual physical, like a second office visit charge and an EKG. These are revenue-generating techniques.

The second office visit will cost you an office copay, which you aren't expected to complain about. You can complain, but the standard response is that you "discussed something outside the scope of the physical."

Don't expect anyone to explain what that "something" was.

♦ Ask for the visit notes. You have a right to your medical records, and most patient portals now show them. If the notes don't show a separate problem was discussed, you have something to point to when you complain.

♦ Private health insurance plans generally must provide coverage for a range of preventive health services without requiring any patient cost sharing. Learn more about preventive services for all adults, women and children.

Emergency Room

Review your plan's summary of benefits carefully.

A trip to the ER is likely to cost you all of your deductible these days.

A trip to an urgent care is more likely to cost you $50 to $100.

• In a real emergency, go to the nearest hospital, in network or not. Your plan has to judge an emergency by your symptoms, and the No Surprises Act protects you from surprise out-of-network bills for emergency care. See Emergency Room.

Testing

Imaging tests like X-rays, CT scans and MRIs usually cost much more than a simple copay. Many plans require prior authorization for MRIs and CT scans.

Some plans now apply these tests straight to the deductible. This could be a big problem for anyone with a high-deductible plan.

• Where you get the test matters. An MRI at an independent imaging center often costs much less than the same MRI at a hospital, which may add a facility fee.

To add to the confusion, some plans have a separate deductible for lab work. These separate deductibles typically range from $350 to $500.

What other benefits does your plan provide?

Many health insurance plans offer extra benefits to encourage people to stay healthy. Most provide programs to help you quit smoking or lose weight, at little or no cost.

Some even provide free health club memberships to prod people to exercise more.

A few go so far as to offer money, in the form of premium discounts, if you complete tasks designed to improve your health, like exercising or losing weight.

Know your network

All insurance plans revolve around a network of doctors, hospitals, urgent cares and testing facilities. These providers have contracted with your insurance company, so there's no arguing over prices.

It's important to know whether your local hospital and preferred doctors are in-network or out-of-network.

♦ Use providers in your plan's network, and your costs will be the lowest.

Go outside your plan's network and you pay more. You may even end up paying it all. You never want to do that.

Know beforehand where the closest hospital is and whether it's in your network. In an emergency, you can use any hospital. Federal law protects you from out-of-network surprise bills.

Urgent Care

Most people will need an urgent care at some point.

Know where your plan's nearest urgent care is and what hours it's open. Write this information down and keep it in an easy-to-find place.

This is where you'll go for urgent needs that aren't life-threatening.

In an emergency or a moment of panic, you don't want to spend precious time calling your insurance company.

Pharmacies

Make a list of the pharmacies in your plan's network, and note whether any are preferred over others.

The preferred ones will cost you the least.

Some plans have high copays for brand-name drugs. If this is your case, you may want to ask your doctor about a generic alternative.

Find a provider

Your insurance company will help you find a network provider near you. Often you can search yourself on your plan's website, or you can call your insurance company.

Searching online is the preferred way. It gives you a chance to learn more about who you might be seeing.

A lot of the time, you can see where the doctor went to school and how many years they've been practicing.

♦ If your insurer's directory says a doctor is in network and it turns out to be wrong, federal law says you generally should only pay in-network costs. Take a screenshot of the directory listing, and write down who you talked to and when.

♦ How do you know if the doctor is any good? This is a tough question.

Sometimes you can ask a family member or friend what they think. Most of the time, we have to take a chance or do some research.

Read more: How to Choose a Primary Care Doctor.

Primary Care Physician

A primary care physician will be your main doctor. They take care of your general health and will refer you to specialists for help with specific illnesses.

• Your primary care doctor is the person you see for your annual wellness check. If you need prescription medicine to control a condition like blood pressure or cholesterol, your primary care doctor will monitor your condition and prescribe medication.

If your plan is an HMO (one type of managed care plan), you're usually required to choose a primary care physician (PCP). This person will be a kind of gatekeeper to other providers, like specialists.

Prepare for your wellness check

Make an appointment with a primary care doctor who is in your plan's network.

♦ When you call for an appointment, reconfirm with the doctor's staff that they accept your insurance plan.

Major insurance companies have several plans. Be sure to ask about your particular plan.

There's always going to be a lot of paperwork. Try to get the forms and fill them out before your visit. You need time to gather information like medical records and family history.

You don't want to be rushed to fill out forms while sitting in the waiting room.

♦ Think about what you want to get out of the visit.

You might want a general checkup to make sure your overall health is good, or you might have specific symptoms or concerns to discuss, like dizziness or trouble sleeping.

• Write a note so you don't forget what to ask.

• Make a list of any medications you're taking, or bring the medicines to the appointment.

• Don't forget to list any over-the-counter medicines, plus vitamins and herbal supplements.

• If you have any lab results, like blood tests, bring them along.

• Be prepared to give the name and phone number of the pharmacy you prefer to use.

• Don't forget to bring your insurance card and a photo ID.

• Most providers don't try to collect a copay for the wellness visit, but just in case, be prepared to pay one.

Did you like your doctor?

Ask yourself this question right after your physical.

Your relationship with your health care provider, especially your primary care doctor, is very important.

You should feel comfortable asking your doctor questions. Your doctor should give you answers you understand.

Do you trust your doctor to give you good medical advice? Trust is critical. If you can't answer yes, you should consider changing doctors.

♦ Unfortunately, a high percentage of patients are afraid to change doctors, even when they understand they have a poor doctor.

Don't stay in that situation. You have the right to change providers for any reason.

• You also need to consider your experience with the doctor's staff. Were they helpful and kind?

♦ Billing issues can make or break a good doctor's office.

Poorly run billing departments will waste your time and cause too much stress. If you feel this way, it's time to seriously look for a new doctor.

Specialists

A specialist is a medical provider with extra training in a specific type of medical condition. Examples are:

Dermatologist: a doctor who treats problems related to the skin. Dermatologists are skin specialists.

Allergist: a doctor who treats problems associated with allergies. Allergies such as hay fever or allergic asthma are handled by this doctor.

• Having some knowledge of the more common types of specialists will be helpful should you need their help one day. Familiarize yourself with Types of Doctors.

♦ Does your plan require a referral to see a specialist? HMO and POS plans usually require a referral from your primary care doctor. PPO and EPO plans usually don't.

Read more about plan types: Health Insurance Plans.

♦ If your plan requires a referral and you see a specialist without one, you're likely to end up paying all the charges.

You must know your plan's rules for specialist visits.