Bookmark and Share

Understanding Health Plan Costs

The costs of health care in an HMO or a PPO can be hard to understand. A health plan may sell different products with different benefits and costs. Some health plans and employers have on-line tools and calculators to help you decide which plan is best for you.

Ask About Costs Before You Join a Health Plan

Talk to your employer or insurance broker, or call the plan.

  • What is the monthly premium? (The amount that you or your employer pays each month.)
  • What is the yearly deductible? (The amount you have to pay each year before the plan starts to pay.)
    • Is there a separate deductible for different kinds of services? (For example one deductible amount for prescriptions and a different deductible amount for other medical services).
    • What costs (e.g. co-pays or co-insurance) or services (e.g. hospital, surgery) apply towards the deductible?
  • What is the yearly out-of-pocket-maximum?
    • This is the total you have to pay each year for most of your covered services. It does not include your premiums. Each family member has a yearly out-of-pocket maximum, and there may be a family out-of-pocket-maximum also. When an individual or family reaches the maximum, they do not have to pay most out-of-pocket costs for the rest of the year.
    • Ask what costs (e.g. co-pays, co-insurance, deductibles) apply towards the yearly out-of-pocket maximum.
    • What is the co-pay or co-insurance that you pay
      • When you have an office visit?
      • For prescription drugs?
      • For a hospital stay?
      • For an emergency room visit?

Are there dollar limits on your coverage?

  • Most health plans cannot put a lifetime dollar limit on your benefits. This means that if you have a serious and costly illness you can still get care. You won’t run out of coverage.
  • Yearly limits for most benefits are ending. They rise from $750,000 to $2 million a year until they completely end in 2014.
  • Some benefits, that are not considered basic or essential, may still be limited.

Follow Your Health Plan's Rules

  • You may have to pay the whole bill if:
    • You see a specialist without a referral from your primary care doctor and prior approval from your medical group or health plan.
    • You see a provider who is not in your health plan's network, unless it is an emergency or you have a referral and prior approval. The network is all the doctors, hospitals, and other providers who have contracts with your plan to provide care to plan members
    • You go to an emergency room for non-emergency care.
    • You get care outside your health plan's service area, unless it is emergency or urgent care.
    • You fill a prescription for a drug that is not on your health plan's list of approved drugs or you fill your prescription at a pharmacy outside your plan’s network.
    • You get services that are not part of your benefit package.

I got a bill for care that I received.

Usually, a doctor, hospital, or other provider in your health plan's network can bill you only for your deductible, co-pay, or co-insurance. If you get a bill for another cost, call the billing office that sent you the bill and ask them to explain the bill to you. If you disagree, file a complaint with your plan. If you are not satisfied with your plan's decision, contact the Help Center.

I got a bill for emergency care that I received.

Your health plan must cover emergency care wherever you receive it. If your plan does not pay the bill, file a complaint with your health plan. If you are not satisfied with your plan's decision, contact the Help Center.

How can I find out how much a service will cost if I have a high deductible?

Ask your doctor, hospital, or other provider for the procedure code for the service you need. Then, call your health plan and ask the cost for this service. Some plans with high deductibles post the costs of common services on their websites.