Guide 2: I Have Health Insurance and Need to Schedule Hospital Care

What do I have to pay for if I have health insurance? How do I lower my out-of-pocket costs?

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 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 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. 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 insurance’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. 

ASK: “Are you part of my insurance network?” 
DO NOT ASK: “Do you take my insurance?” Some providers who are out-of-network will say they “take” your insurance — but what they mean is that they will bill your insurance. This isn’t the same thing as being “in network.”

What if I get a bill from an out-of-network provider?

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 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 amounts above what your health insurance plan will pay. 

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 consent form should be provided at least 3 hours before a procedure. 
• For all other scheduled care, you must be given the consent 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 ER physicians (because ER care is protected against “surprise medical bills”)
• Assistant surgeons
• Anesthesiologists
• Radiologists or imaging services at an in-network hospital
• Hospitalists
• Intensivists
• Pathologists
• Neonatologists

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?

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 health 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.

Some states have restrictions on facility fees, such as prohibiting facility fees for preventive services, telehealth services, or evaluation and management services outside a hospital. Some states require doctor’s offices that charge facility fees to post signs notifying patients that they may be charged a facility fee. 

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. For instance, some states and nonprofits offer used medical equipment at no cost to local residents, or you may be able to borrow the necessary equipment. You may also be able to purchase it at a lower cost online or at a pharmacy. 

Can I know my health care costs before I receive care?

Can I know my health care costs before I receive care?

For any care that is scheduled in advance — like a colonoscopy or non-emergency surgery — we recommend you contact your health insurance plan to discuss your coverage and what you can expect to pay for that treatment. If possible, get that estimate in writing.  

Hospitals are required to post prices on their website. You will need to know the name of your procedure or the different billing codes to look up prices. These posted prices are not guaranteed but could be helpful to get a sense of your costs ahead of time. Here are tips on how to look up hospital prices.