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Helping Texans Compare & Understand Their Health Care Options

Compare Other Health Plan Costs

Cost Sharing

If you’re not familiar with cost sharing or where to find a plan’s cost-sharing information, read Comparing Cost Sharing.  When comparing a plan’s cost sharing, ask yourself the following questions:

  • What are the plan’s deductibles?  Some plans have different deductibles for different types of services.  For instance, there may be a deductible for medical services and a deductible for prescription drugs.  Some services may be exempt from the deductible.  
  • What is the coinsurance after I meet my deductible?  When you get health care services, you and the plan will usually each pay a portion of the cost.  “Coinsurance” is the amount you pay.
  • Is there an out-of-pocket maximum where my plan begins to cover everything?  A lower out-of-pocket maximum will limit how much you pay in a given year if you have high health costs.
  • What are the specific copayments (copays) for each kind of service?  Copays are amounts that you have to pay each time you receive a health care service.  For instance, you might have to pay a copay each time you go to the doctor or fill a prescription.  
  • How much will I have to pay for a primary care, specialty care, or behavioral health visit?  Check and see what a plan will require you to pay when you go for a primary care, specialty care, or behavioral health visit.  
  • How much will it cost me to go to the emergency room?  Knowing what a plan will require you to pay helps you prepare for the out-of-pocket costs.
  • How much will it cost me to go to an urgent care clinic?  Find out what a plan will require you to pay for urgent care visits if you need after-hours care or can’t wait for an appointment with your primary care doctor.
  • Will I have to pay more if I see an out-of-network provider?  Some plans will let you visit out-of-network providers while others won’t.  You will usually pay more for an out-of-network provider.  If a plan lets you use out-of-network providers, find out what the plan will require you to pay to use them.  Learn more about networks and network types.

Limits and Exclusions

Health plans don’t cover everything.  For instance, a plan might limit how many doctor visits it will cover each year.  A plan may exclude some services or procedures.  If you’re not familiar with benefits and exclusions or where to find them, read Comparing Benefits.  Here are some questions to help you compare plan exclusions:

  • What services does my plan not cover?  Read the fine print to understand what services the plan doesn’t cover.  If you’re managing a medical condition, read the terms and conditions related to the benefits you plan to use.  Some plans also require you to get prior authorization before you receive a health care service.  
  • Are there limits on the number of visits to a provider, like a behavioral health provider or physical therapist?  Some plans will limit the number of doctor visits they’ll pay for.  
  • Do I need a referral or prior authorization to see a specialist?  Make sure you know whether you’ll need referrals before buying a plan.  For example, in an HMO your primary care doctor acts as a gatekeeper and must give you a referral to see a specialist.  If you don’t get a referral, you may have to pay the full cost of your care.

Network of Providers

The cost of care affects your premiums.  Health plans try to lower costs by forming networks and negotiating contracts with providers.  

If you already have a doctor, check to see whether your doctor is in the networks of the plans you’re comparing.  If not, you’ll either have to choose a new doctor that is in the network or find a plan that will allow you to keep your doctor.

Check the plan’s provider directory to see the network status of the doctors and other hospital-based providers at your hospital.  For each hospital listed in the directory, you can see the percent of claims billed by doctors who are out-of-network.  This gives you an idea of your risk of receiving a surprise bill for care at that hospital.  This information may be in a document with the provider directory.  Ask the health plan if you can’t find this information.

Learn more about networks and network types

Prescription Drugs

Ask the following questions to help you compare drug benefits.  You can use a plan’s drug formulary to compare prices before you buy a plan.

  • Do I want prescription coverage?  Make sure to compare drug coverage, especially if you fill prescriptions regularly.
  • How much do I have to pay for prescription drugs?  Make sure you know how much you would pay for prescription drugs.  
  • Do I require brand name drugs or can I use generic drugs?  Most plans charge different amounts for generic, brand name, and specialty drugs.  If a generic drug isn’t available to meet your needs, compare coverage for any medications you take.

Next Section: Rules That Health Plans Follow

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Last updated: 10/06/2015