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Your Health

Getting what you want from your health plan: No surprises

Nov 06 2015

We all want the same thing from our health plan – no surprises.

Here’s what you can do now so you’re not caught by surprise when you start using your plan.

Know the network. Is your doctor in it? The specialist your doctor recommended? The urgent care center down the road, or the academic medical center you might need? The most convenient pharmacy? Check before you choose your health plan and before you make an appointment. If you go to a doctor, pharmacy or hospital that’s not in your plan’s network, you could be in for some bad news when the bill comes.

Out-of-network health care providers can charge you whatever they want, and your plan generally covers less than it would in-network. Some plans don’t cover care outside their networks at all. A few minutes on your health plan’s website or smartphone app or a call to customer service before you make an appointment or schedule a procedure can save you an expensive surprise.

Compare prices. Chances are you wouldn’t buy a television or a coffee maker without comparing prices at stores or online. Why wouldn’t you do that for health care, which could have much higher price tag? Even inside your plan’s network, costs for the same services in the same community can be very different from one place to the next.

Many health plans offer their members “cost of care” tools that let you check out prices for common services ahead of time. Aetna’s member payment estimator, for example, lets members compare costs for over 650 medical tests, services and procedures at up to 10 doctors, hospitals or other facilities at once. Tools like these can avoid surprises after the fact, particularly if you haven’t met your deductible yet and so are paying the full cost, or if you have met your deductible but are paying a percentage of the cost. A big bill can be hard to pay when you’re not expecting it. Speaking of deductibles…

Know your deductible and what counts toward it. Some plans have deductibles of a few hundred dollars, while others are in the thousands. Except for preventive care, which most plans cover entirely, you’ll have to pay the full agreed-upon amount for most care and drugs until you’ve met your deductible. After that, your plan will cover some or all of the cost. Don’t be caught by surprise when you have to pay a bill in full. Know your deductible and keep track of where you are during the year.

And here’s something else that could surprise you: Care outside the network often doesn’t count toward your deductible. That’s yet another reason to stay in network.

Know what your plan covers. Do you take a brand-name drug? See if it’s on your plan’s formulary, or drug list, and how much you would have to pay for it. If it isn’t on the plan’s list, or would be quite expensive, ask your doctor about a generic or a different brand that would work just as well. Ask before it’s time to refill your old prescription, or you could get sticker shock at the pharmacy counter. Where you get your medications can also affect how much you pay. This can be particularly important if you take specialty drugs.

Do you expect to need a certain type of care – a surgical procedure, say, or counseling? Check the plan documents, like the Summary of Benefits and Coverage, for an overview of what’s covered and an idea of what the plan pays. Then you can be prepared to pay your share.

Plan ahead for other costs. People are sometimes surprised to learn that health plans generally don’t pay for some kinds of care, such as special dietary supplements, an aide for a homebound family member or admission to a long-term care facility. It’s important to come up with alternative ways to pay for bills like these if you expect them. You may be able to open a Health Savings Account to pay for some care that isn’t covered with pre-tax dollars.