How to avoid costly mistakes with your health plan

1. Use your plan’s network

   Health plans usually want or require you to use their network of doctors, facilities, and specialists. Call your health plan to ask if the doctors or facilities you use are in the network.

   If they aren’t in network, you’ll pay more out of the cost.

2. Get a referral when you need one

   Ask your health plan if you need a referral from your primary doctor to see a specialist. Also ask if you need to get a pre-approval (known as preauthorization) from your plan before getting treatments. If the treatment isn’t pre-approved, your plan might not pay for it or you might have to pay more of the cost.

   After you get a referral, ask your plan if the specialist and facility you’re referred to are in your plan’s network. Your doctor might not know if the specialist or facility are in your network.

3. Know your options

   How much you’ll spend at a medical appointment depends on what type of provider you see. Most plans will cover a phone call with a nurse, an online appointment, and visits to a doctor’s office, an urgent care clinic, or a hospital emergency room.

   Nurse lines and online visits are usually cheapest (and often free). Emergency rooms are the most expensive. Don’t confuse urgent care clinics with emergency rooms that aren’t in a hospital. Urgent care clinics are usually much cheaper.

4. Know what type of plan you have

   Ask the plan you’re thinking about buying if it’s a “major medical plan.” This is traditional health coverage, the kind you get through your employer or buy on Healthcare.gov. It covers a wide range of services if you get sick or hurt. You might also know them as HMOs, PPOs, or EPOs.

   There are other types of plans that don’t cover a wide range of services. They usually offer fewer benefits and have lower coverage amounts than major medical plans. And they often don’t have to follow state or federal rules.

Other tips

• Ask how much you’ll pay out of pocket for copays, coinsurance, and deductibles.
• Know about your plan’s appeal process and how to ask for an independent review if a health care service is denied as “not medically necessary.”
• Shop for a health plan that has the coverage you want and includes your doctors and prescriptions in network.

Resources

• Health insurance: 5 things you may not know
• Use these tips to shop smart for health coverage.
• Four ways of getting health care to avoid big bills
• How consumers are protected from surprise medical bills