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Ten tips to make the most of your health benefits

Jan 10 2016

You have your new health plan ID card for a new year. Now what? How can you avoid unpleasant surprises when the bills start to come in for your care? And how can you get the most for your money? (And don’t miss Five ways to make the most of your drug benefits and You might have these health plan benefits — and not even know it.)

1. Know what you bought.

Take a good look at two important documents. First is the Summary of Benefits and Coverage. You received this when you enrolled in your plan. Pay attention to your deductible, your copays or coinsurance, and your out-of-pocket maximum. In many plans, you pay the full amount of most medical bills until your costs have added up to the deductible. After that you will owe part of the bill until you have hit the plan’s out-of-pocket maximum.

2. Know what’s covered.

Second is your plan document. It has a long list of medical services that your plan does or does not cover. Don’t wait until you are in the middle of treatment to learn whether something is covered. Check out your plan document online or in your package from your plan. If you can’t find it, call your health plan and ask how to get one.

3. Know how much it will cost.

Even though you have coverage, you can pay more at some places than others for the same care. Can your plan tell you how much something will cost before you get care? Most can give you some idea. Some can tell you exactly how much it will cost at specific doctor’s offices or hospitals. Be sure to check your plan’s website or mobile app, and be a smart shopper.

4. Choose a doctor.

Your primary care physician, or PCP, is a doctor who is typically part of your plan’s network. If your plan requires referrals, this is also the doctor who will give you referrals to specialists, such as allergists or dermatologists. Check your insurer’s website for a list of doctors in your area who are in your plan’s network. Be sure to look specifically at the network for your plan. Some doctors are in some of an insurer’s networks, and not others.

If you have your eye on a doctor who is not in your plan’s network, you will have to pay more to see that doctor. Be sure to ask about extra out-of-pocket expenses you may have to pay to see this doctor. Your plan may not pay anything at all for doctors who are not in the network.

5. Ask the right questions

If you’ve narrowed down your list to several doctors, you may want to learn more about them to determine who is the best fit for you. Here are some questions to get you started:

  • Is the doctor accepting new patients?
  • What are the office hours?
  • Does the doctor have a subspecialty that fits your needs, such as experience working with children, the elderly, or people with disabilities?
  • Is the doctor available over the phone during office hours? If not, is there a nurse who can answer your questions?
  • Does the doctor use e-mail?
  • Does the practice include physician assistants or nurse practitioners?
  • What hospital(s) does the doctor use? (You should check if that hospital is in your plan’s network. If not, choose a different doctor or pay MUCH more for hospital care.)
  • How long does it take and how easy is it to book an appointment?
  • Will the office send you the new patient forms ahead of time, to cut down on your time in the waiting room?

6. Know how to get specialized care if you need it

Specialists are experts who practice one specific area of medicine. To find a specialist:

  • Check your health plan’s network.
  • Find out if your plan allows you to see a specialist without a referral. Some plans require that your PCP refer you to specialists like allergists and dermatologists. Make sure that any specialist or facility that you are being referred to is part of your specific plan’s network.
  • Visit the website of an organization or academy associated with your specialty needs.
  • Check your local or regional monthly magazine for a directory or ranking of specialists in your area.
  • Ask your primary care physician, family and friends for recommendations.
  • If you’re having trouble getting an appointment with a specialist, call your PCP – they might be able to help.

7. Prevent problems before they start

Many plans cover preventive care at no cost to you. This means you pay nothing out of pocket for services like annual physicals and GYN appointments, mammograms and other screenings, vaccines and more. These are important steps to staying healthy, so take advantage of them!

8. Know if you need approval for some care 

Under some health plans, you need prior approval for particular medical services, called preauthorization or precertification. Check your plan documents to see if there are any services that require prior approval. If so, who has to request it – you or the doctor or facility providing the service?

9. Know what tests are covered and where

Before going for any tests or lab work, such as X-rays and diagnostic services, find out what’s covered by your plan. Find out if your plan requires you to use certain labs or facilities. Use your plan’s tools to compare the cost of a test at different local facilities — you’d be surprised how different the cost can be. Work with your doctor to try to schedule many tests at once, or call ahead to try to schedule lab work during one of your regularly scheduled check-up appointments.

10. Be ready for an emergency

While you can never plan for the unexpected, emergencies happen. It’s important to check your plan documents to find out what emergency services are covered. You should also find out if your plan offers an emergency 24-hour hotline or nurse helpline. If you are unsure whether you need to visit the emergency room, try calling the hotline first. An urgent care center in your plan’s network, rather than a hospital emergency room, may be a good choice for some emergencies.