Even if you have a health plan, you will still have some costs. Ask your health plan or doctor the questions below to understand how much you will have to pay for the care you and your family receive.

Choosing a Healthcare Provider

If you visit a doctor, hospital, or other healthcare provider that does not take your plan, you may have to pay more. Ask your plan how to avoid or deal with for extra costs:

1. Are my doctors/dentists members of the plan’s network?
2. How can I look up doctors/dentists who take this plan?
3. Where can I get a list of doctors/dentists in my area?

Ask the questions in the FH Quality Toolkit when you are choosing between healthcare providers.

Visit the Resources Section for tools you can use to find healthcare providers.

Tracking your Deductible

Your deductible is the amount of money you have to spend before your plan starts paying for your care. You may have different deductibles for doctors who take your plan (in-network providers) and those who don’t (out-of-network providers). You also may have a separate deductible for different types of care and prescription drugs. Keep track of all your receipts, and check in with your insurer to make sure their information matches yours.

1. What are my deductibles?
2. What services count toward my deductible? Do both in-network and out-of-network services count towards the same deductible?  Do pharmacy services and laboratory services count towards the same deductible? Will they count even if I go to a doctor who is not in my plan?
3. How do I know when I have met my deducible?

Prescription Medications

Make sure any regular medications you take are covered by your plan, and that you know how to get them. For example, some plans require you to use a generic version of medications, or order daily medications in three-month supplies instead of refilling them at your pharmacy.

1. Are my regular prescriptions covered?
2. How much do I have to pay for prescriptions?

Before Going Out-of-Network

Are you considering seeking care from a healthcare provider who does not participate in your plan’s network?  Avoid financial surprises by doing your homework in advance. Use the helpful questions below when you speak with your healthcare provider and health plan.

Ask Your Healthcare Provider

1. Do you participate in my plan’s network?  If not, how much can I expect to be billed for my visit?
2. Will my insurance plan’s payment cover the full cost of this out-of-network visit? If not, will you expect me to pay the difference between your bill and what you are paid by the insurance company?
3. What tests/lab work will be ordered for my visit?  Will they be covered by my health plan? Will you use an outside testing site/lab, and if so are the tests/lab work considered “in-network” under my plan?
4. Will your office check with my plan to determine if pre-authorization or a referral is required for any tests or procedures?
5. Will you be performing or ordering services not typically covered by my plan?
6. Can you tell me which procedure codes you will be likely to submit for the services I will receive? (CPT® or HCPCS codes for medical; CDT®  codes for dental)
7. Do you offer payment options, discounts, or otherwise negotiate your fees, for services that are out-of-network or not covered by my plan?
8. Are the medications you prescribed covered by my plan? If not, is there a less expensive alternative such as a different brand or generic option that is covered?
9. If you are prescribing a drug that must be administered in the physician’s office, is there an alternative such as a pill or injection that can be self-administered?
10. Will my surgery/procedure be performed at an in-network facility? Will all of the providers (anesthesiologist, radiologist, etc.) that I see at the hospital or outpatient facility be part of my plan’s network?  If not, can you provide me with contact information for these providers so that I can obtain information to help me plan for my healthcare expenses?

Ask Your Plan

1. What are the rules for accessing care outside my plan’s network?  For example, how will I know if a service or test needs to be pre-authorized?  Is there a phone number that I need to call?
2. Do I have to get pre-authorization or a referral for certain in-network services?
3. What types of care are covered by my plan? Will they be covered if performed by an out-of-network provider? What services or tests are excluded?
4. What is your definition of screening tests?   Do I have to pay a co-pay or meet a deductible to have a screening test if it is recommended by my doctor?
5. What happens if my in-network provider sends lab tests to an out-of-network laboratory?  Would I be responsible for additional costs?  If so, how can I be sure my provider uses an in-network laboratory?
6. How can I confirm that all providers who will provide care during a procedure, surgery or hospitalization (e.g., anesthesiologist, radiologist, pathologist) participate in my plan’s network?
7. How does the plan cover emergency services from a non-network provider?   How does the plan define “emergency” services?  If I am brought by ambulance to a non-participating Emergency Room, am I financially responsible for a decision that was not in my control?

Back to Top

If you can’t afford care or receive an unexpected bill, you can negotiate the cost or appeal using your FAIR Health cost estimate, which you can obtain on the cost lookup tool. If you have questions about your bill, call your plan first and ask them to explain. Compare your bill to the estimate on this website to see the typical cost of the service in your area. This will help you decide if you would like to pay the full cost, negotiate the cost with your healthcare provider or send an appeal to your health plan if it paid less than you expected. Your plan document should provide information about the plan’s appeal process. Or, you can call your plan and ask for instructions on filing an appeal.

Each medical service, test, and supply you receive has a specific CPT® code, and the price you and your plan pay is based on that code. Knowing that code will make it easier to talk about the service with your plan and your healthcare provider.

Negotiating the Cost of Care with a Healthcare Provider

If you are planning to visit a doctor who does not take your plan, you can use the cost estimate obtained on the cost lookup tool to negotiate the price.

1. What is the name of the procedure that I need to have? What is the procedure code that you will use for it? How much do you charge for this treatment or procedure?
2. I have a copy of the FAIR Health cost estimate that shows the typical charge for this procedure in this area is lower than what you charge. Would you be willing to accept a lower price?

Appealing with Your Insurer

If your health plan paid less than you expected, you can use your cost estimate to appeal.

1. My plan won’t pay for this service, or paid less than I expected. Ask your plan representative: Why?
2. Ask your provider: Can you confirm the procedure code so I can make sure it matches the service that I received on my bill and explanation of benefits (EOB) form?
3. Check your plan document or ask the plan representative: How can I appeal this decision?

Back to Top