Planning Your Costs Based on Where You Get Care
Summary
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.
Doctor’s office.
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.
Other settings
- 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.
Where You Get Care May Affect Your Costs
Different healthcare settings may bill differently. For instance, when you see a doctor, you’ll receive a bill with a “professional” fee for the visit. But if you receive a test at a lab, have surgery in a hospital, an x-ray at an imaging center or sometimes when you visit a doctor’s office that is owned by a hospital system, there may also be a “facility” fee for the use of that location. In some cases, the fees may be lumped together into a single charge, so it won’t be clear on your bill. Some insurers may require you to have certain services in certain settings, so make sure to check with your plan before deciding where to go for care.
Your Action Plan: Know Where to Go
- Know your plan’s rules before you get care. For instance, your doctor might offer to give you an X-ray or scan at their office, but your plan may only pay if that test is authorized in advance, and you have it at an imaging center.
- Before you receive a service, ask your doctor what charges you can expect. Will there just be a professional fee, or will a facility fee be added? Will the two be combined? Will you have one copay or two?
- Ask your plan whether your service or procedure will cover the costs of the procedure and whether it needs to be pre-authorized.
- Make sure the doctors and facilities you visit are in your plan’s network by checking your plan’s website, or calling a representative. Double-check with your provider, too, since this information can change.
- If you choose a healthcare setting outside your network, check with your plan first and see if it will pay for out-of-network care, and if so, how much it will cover. If it does not cover any out-of-network care, ask the provider how much the charge will be, and if you would be able to negotiate a lower rate or sign up for a payment plan.
- If you are not insured, you may be able to get care through a low-cost community health center. You can find a clinic or FQHC near you by visiting http://findahealthcenter.hrsa.gov/