Using Health Insurance

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Using Health Insurance


Using health insurance without racking up huge expenses is not easy.

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.

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

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

• Using insurance to cover routine health care and prevention so as to avoid more serious health problems.

Studies have found that only 14% of Americans between the ages of 25 and 64 have a firm understanding of the most basic concepts of health insurance.

There is also a perception gap with nearly 50% of Americans thinking they have a solid understanding of health insurance when they actually do not.

Health insurance is confusing and complex. Becoming more knowledgeable and aware 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 are avoiding seeing the doctor out of worries over 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 that everyone should take advantage of.

Staying healthy requires some effort, like getting regular check-ups. Check-ups 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 cannot remember, you are overdue. You need to get moving.

Don’t wait until you are 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 insurance 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 is a brief written description of services and costs you are expected to share.

The SBC is usually very brief and does not go into much detail. A plan’s details can be found in a document called a Benefits Booklet. It will go into detail about how the plan will deal with various situations.

• X-rays taken during an office visit are usually covered under the office copay while x-rays performed at an out-patient facility may cost much more.

The SBC is a good start. Your insurance company usually sends this information 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 you must be careful to find information on your particular plan.

If you are not certain, do not 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 will want to consult your plan’s Benefits Booklet more than the SBC, so it would be good to have a copy of this document.

♦ 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. This includes basic bloodwork.

Some words of caution though - all may not be free.

♦ Most medical practices are coming up with creative ways to tack on additional charges to the annual physical visit, like two office visit charges and an EKG. These are revenue generating techniques.

The second office visit will cost you an office copay, which you are not expected to complain about. You can complain, but the standard response is that you “discussed something outside of the scope of the physical.”

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

♦ 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

Your plan’s summary of benefits should be reviewed carefully.

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

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


Lab tests like X-Rays, Cat Scans and MRI’s are going to require you to pay much more than a simple copay.

Some plans are now applying these types of tests straight to the deductible. This could be a big problem for anyone with a high deductible plan.

To add to the confusion, some plans have a separated deductible for "laboratory services." 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, at little or no cost, programs to help quit smoking or lose weight.

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

A few go so far as to off money in the form of premium discounts if you complete some tasks designed to improve your health, like exercise and losing so many pounds.

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 is no arguing over prices.

It is important to understand if 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 of your plan’s network and you pay more. You may even end up paying all. You never want to do that.

Know beforehand where the closest hospital is and if it is in your network. If you have a true emergency you can still use an out-of-network hospital.

Urgent Care

Most people will need an urgent care at some time.

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

This facility is where you will go for non-life threatening but urgent needs.

In a time of an emergency or panic moment you do not want to spend precious time calling your insurance company.


Prepare a list of the pharmacies that are in your plan’s network and if any are preferred more so than another.

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 consider asking your doctor for a generic alternative.

Find a provider

Your insurance company will help you locate a network provider near you. Often times you can search yourself at 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 he or she has been practicing.

♦ How do you know if the doctor is any good or not? 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. He or she takes 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 insurance plan is a Managed Care (HMO), you are usually required to select a PCP (primary care physician). 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 that is in your plan’s network.

♦ At the time you call for an appointment be sure to 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 is always going to be a lot of paperwork. Try to get the forms and fill them out before visiting. You need time to gather information like medical records and family history.

You do not 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 check-up to make sure your overall health is good, or you might have specific symptoms or concerns you want to discuss, such as dizziness or trouble sleeping.

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

• Prepare a list of any medications you are currently 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 test, be sure to 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 do not attempt to collect a copay for the wellness visit but just in case be prepared to pay the copay.

Did you like your doctor?

Immediately after your physical ask yourself this question.

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 that you understand.

Do you trust your doctor to give you good medical advice? Trust is critical. If you cannot 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 remain in such a 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 your feel this then it is time to seriously look for a new doctor.


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

Dermatologist - This is a doctor that treats problems related to the skin. Dermatologists are skin specialists.

Allergist - This is a doctor who treats problems associated with allergies. Allergies such as, hay fever or 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 you to have a referral to see a specialist. HMO type plans usually require a referral from your primary care doctor.

PPO and POS type plans do not.

Read more about plan types ...Health Insurance Plans

♦ Should your plan require a referral and you see a specialist without the referral you are likely to end up paying all charges.

You must know your plan’s rules dealing with specialist visits.

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