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?
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.