Planning Your Costs Based on Where You Get Care
Your plan may have different rules and costs for different healthcare settings. In any setting, you may have to pay a copay, and in some cases, coinsurance. But, these may be waived for preventive services like flu shots and mammograms.
Day-to-day care at your family doctor’s office is usually covered by health plans. Your plan may require a referral from your primary care physician (PCP) to see a specialist.
Outpatient settings (same-day care)
- Hospital outpatient centers—for services like physical therapy and chemotherapy. You may need preauthorization, or approval from your insurer before you go.
- Imaging centers—for radiology procedures like CT scans and ultrasounds. You may need preauthorization.
- Labs—for blood tests.
- Ambulatory surgery centers (ASCs)—for surgeries and tests, like colonoscopies, that don’t need an overnight stay. You may need preauthorization.
- Hospital emergency rooms (ERs)—for treating a sudden, serious sickness or injury. The copay is usually higher than for other settings. But, it may be waived if you are admitted to the hospital. Most plans only cover visits to the ER for “true” emergencies. If you visit the ER for routine care, you may have high out-of-pocket costs.
Inpatient settings (need an overnight stay)
- Hospitals—for short-term care for a serious sickness or injury. You may need preauthorization.
- Rehabilitation (rehab) centers—for care after sickness or injury. For instance, you may get physical therapy for a hip replacement, before you’re well enough to go home. Or, you may get therapy for substance abuse. You may need preauthorization.
- Your home—for help recovering from surgery or treating a serious sickness. You might get visits from physical or occupational therapists or home health aides. You may need preauthorization.
- Urgent care centers—for when you don’t have an emergency but you need care quickly. Costs are most often lower than for an ER visit.
- Retail clinics—for basic medical care if your regular doctor isn’t on hand. Most, but not all, take insurance.
- Community health clinics and federally qualified health centers (FQHCs)—for low-cost care. If you are not insured, they may offer a sliding fee scale based on your income and family size.
When you need care, the first stop is usually your family doctor’s office. But your health plan may have rules about where to go for certain services or medical procedures. Your health plan contracts with a wide range of doctors and providers across different settings, such as primary care physicians, nurse practitioners and specialists to urgent care centers, hospitals, labs and radiology facilities. Before you go, find out what your plan requires, and if the office or facility you plan to visit is in your plan’s network. Otherwise, you may have higher out-of-pocket costs.