What do I have to pay for if I have health insurance?
When you have health insurance, charges fall into different categories. Here are the terms to know.
This is the amount that must be paid every month to maintain your health insurance. Some employers pay all or part of your monthly premium.
This is an annual amount that you must pay for health care services that occur before your insurance starts to cover your costs. The amount that you pay in copays and coinsurance (see below) do not count toward your deductible.
For example: Your annual deductible is $2,000. The first time you visit a doctor that year costs $1,500. You are responsible for the full amount of that bill: $1,500. If you need additional medical care that same year, you still have to reach the deductible amount — in this case, $500 more to hit $2,000 total — before your insurance starts to pay its share. Once you’ve paid $2,000 in medical bills that year, you have “met your deductible.” Now insurance starts to cover your health care bills — except for copays or coinsurance (see below).
This is a set amount ($10, $25, etc.) that you must pay for certain appointments and services, such as a doctor’s check-up or bloodwork.
This is an additional out-of-pocket cost that some insurers require you to pay (for particular appointments and services) after you have met your annual deductible. The amount of coinsurance you pay is based on a percentage of the amount billed for the provider.
For example: If your bloodwork cost $400 and you have 10% coinsurance, you will be asked to pay $40 — in addition to your copay.
Most plans have an out-of-pocket maximum, which is the most you have to pay in medical costs during your insurance policy’s year. Deductibles, copays, and coinsurance count toward your out-of-pocket maximum. Note that your monthly premium payments do not count toward your out-of-pocket maximum.
For example: If your plan has a $5,000 out-of-pocket maximum, you can add up all the amounts you paid in copays, coinsurance, and deductibles. If those expenses add up to $5,000, your insurance will begin to pay 100% of any additional medical care covered by your insurance until it is time to renew your insurance for the next 12 months.
Essential care coverage
Most plans fully cover the cost of preventive care, meaning you won’t even owe a copay. Check with your health insurance plan to be clear what kind of care, screenings, and vaccines it covers with no out-of-pocket cost to you.
How do I lower my out-of-pocket costs?
Get your care from in-network providers
You will pay less out-of-pocket if you choose a doctor and hospital that are part of your health insurance plan’s network. Most health insurance plans have a list of in-network doctors and hospitals on their website. You can also call the number on the back of your insurance card to get help finding an in-network provider.
- When you choose a doctor and hospital in your health insurance plan’s network (also known as an in-network provider), you only have to pay your in-network copay, coinsurance, and any remaining amount of your deductible.
- If you choose a doctor or hospital that is NOT part of your health insurance plan’s network, you end up paying more:
- Your copay is often higher. For example, if you normally pay a $10 copay, you may have a $25 copay for an out-of-network provider.
- Your coinsurance percentage is higher. For example, if you normally pay 20% of your health care charges for an in-network doctor, you may have to pay 40% for an out-of-network doctor.
- You may receive a “balance bill.” This is the difference between what your health plan’s insurer covers and what an out-of-network provider charges. (Also known as “balance billing.”) Some out-of-network providers are allowed to send you a balance bill — any amount of their bill that your health insurance plan did not pay. (You may have some protections from balance bills.)
- Any amount paid to an out-of-network provider does not count toward your deductible.
- In certain cases, you may have a health insurance plan (like an HMO) that will not cover ANY out-of-network care. If you have this type of health insurance plan and receive out-of-network care, you will have to pay the FULL amount of an out-of-network provider’s bill. If you are unsure about your plan’s out-of-network policies, call the number on the back of your health insurance plan’s card for more information.
Sometimes, it is hard to find an in-network provider.
Here are some tips:
Health insurance companies have an extensive list of doctors and providers who are in their network. However, if a doctor — or even an entire hospital — leaves an insurance network, the health insurer’s network directory may not be updated immediately. That’s why it’s essential to double check to make sure you have chosen a doctor, laboratory, imaging service, or hospital in your health insurance plan’s network.
- If you use your insurer’s online network directory to choose a doctor, take a screenshot of the page that lists your doctor as in-network. Keep this image as a record so you can prove that you relied on information on your health insurance plan’s website.
- When scheduling your appointment, ask to make sure the doctor or hospital is still part of your insurance network.
What if I get a bill from an out-of-network provider?
Sometimes, even if you carefully choose an in-network doctor and hospital, you may still receive care from an out-of-network health care professional. The No Surprises Act is a federal law that protects you from out-of-network “surprise medical bills” — even in non-emergency situations at an in-network hospital.
Be careful with forms
Some out-of-network doctors are allowed to ask you to sign a “Surprise Billing Protection Form,” which allows them to bill you for out-of-network services that aren’t covered by your health insurance plan. This form might be in the stack of paperwork you are given when scheduling your care. The form must include an estimate of what that treatment will cost for that out-of-network doctor or service. Do not sign this form unless you agree to the terms and are willing to pay more for out-of-network services.
Keep in mind
- You always have the right to ask for an in-network doctor if you are at an in-network health care facility. You should never be pressured to sign a “Surprise Billing Protection Form.” If you felt pressured to sign this form, file a complaint or call 1-800-985-3059.
- You should NEVER be given a “Surprise Billing Protection Form” if you’re being treated for an emergency.
- If you sign this form, you’re giving up your No Surprises Act protections from expensive “surprise medical bills.” Your signature means that you agree to allow your out-of-network provider to bill you for any services your health insurance plan won’t cover.
Who can ask me to sign a “Surprise Billing Protection Form”?
There are two common scenarios where you may be asked to sign a “Surprise Billing Protection Form”: 1) when you are scheduling hospital care, such as a surgery, or 2) when you’re already in the hospital and you need some type of unexpected care.
- For care that is scheduled for the same day, the form should be provided at least 3 hours before a procedure.
- For all other scheduled care, you must be given the form at least 72 hours before a scheduled procedure.
For example: You are scheduling surgery for a hip replacement with your specialist who operates at a nearby hospital. That specialist — in this case, a surgeon in charge of your procedure — may be an out-of-network provider. That surgeon may ask you to sign a “Surprise Billing Protection Form” in advance of the surgery. The form must include a cost-estimate of what you will owe. It must also be provided at least 72 hours before your hip replacement surgery. If you sign the form, you are consenting to paying the out-of-network balance bill. If you do not consent to care from an out-of-network surgeon, request to be treated by an in-network surgeon and do not sign the “Surprise Billing Protection Form.”
These providers are not allowed to ask you to sign this form:
- Emergency rooms or E.R. physicians (because E.R. care is protected against “surprise medical bills”)
- Assistant surgeons
- Radiologists or imaging services at an in-network hospital
If you are asked to sign the form by any of these providers or their staff while you are receiving emergency care, DO NOT SIGN the form. Report this violation immediately: Call the No Surprises complaint line at 1-800-985-3059 (8 a.m. to 8 p.m. ET) or file a complaint online.
Are there other fees I should ask about?
Be aware of “facility fees”
Some health care facilities charge “facility fees,” in addition to regular bills for medical services. Facility fees are often charged at hospitals — including emergency rooms and outpatient centers — or at clinics and doctor’s offices that are owned by a local hospital. These offices may look like a regular doctor’s office, so be on alert.
Sometimes health insurance plans don’t cover facility fees, or they only cover part of a facility fee. Call the location where you plan to receive care and ask if you will be charged a facility fee. If the answer is “yes,” call your insurance company to see if they will fully cover this expense. If your insurer will not fully cover a facility fee, ask your doctor or your insurer to help you to find an alternative location that won’t charge these added fees.
Ask about equipment costs and any follow-up care
Sometimes you need additional care or medical equipment after your treatment. Make sure to ask your provider about medical equipment you may need after your treatment, such as crutches or a wheelchair. If you do not need the equipment, you do not have to take it, even if it’s offered by your provider.
If you are unsure of whether or not you either need medical equipment — or if that equipment is covered by your insurance — ask the health care worker who is discharging you to verify if medical equipment and/or follow-up care is necessary as well as its associated out-of-pocket costs. Remember, your provider or caretakers are there to help YOU. Lean on them to help you navigate the system.
If your insurance coverage is insufficient, ask your health insurance company for ways you can keep equipment or follow-up care costs at a minimum.
Can I know my health care costs before I receive care?
Yes! Ask for an “advance explanation of benefits.”
For any care that is scheduled in advance — like a colonoscopy or non-emergency surgery — you may ask your health insurance plan to provide an estimate of what you will owe. This is referred to as an “advance explanation of benefits.” The plan may provide this estimate in writing, but they are not required to.
If you get an estimate, be sure to compare it with the Explanation of Benefits (EOB) that you receive after you receive your scheduled care. Ask your health insurance plan to explain anything that does not match up.
More guides in this series
Senior Director, Health Care Campaigns, U.S. PIRG Education Fund
Patricia directs the health care campaign work for U.S. PIRG and provides support to our state offices for state-based health initiatives. Her prior roles include senior director of health policy with the National Consumers League, senior policy advisor at NJ Health Care Quality Institute, and consumer advocate at NJPIRG. She serves on the board of the Patient and Caregiver Engagement Advisory Group for the National Quality Forum. Patricia enjoys walks along the Potomac and sharing her love of books with her friends and family around the world.
Quỳnh Chi Nguyễn
Associate Director, Community Catalyst, Center for Community Engagement in Health Innovation
Quỳnh Chi Nguyễn oversees two major projects on community benefits and economic stability, and hospital equity and accountability. She also supports local and state health advocacy organizations that are working to improve economic stability. Quỳnh Chi has expertise in several policy areas, including affordability, health insurance coverage, prescription drug costs, and health justice. She is similarly experienced in policy research and analysis on community sustainable development, poverty reduction, child protection, and human trafficking in Southeast Asia.