How Members Can Use Their Health Plan to Manage Costs

Many companies — maybe yours — are choosing or considering health plans that require their employees to share in the cost of their care to help lower health care costs. Here is some helpful information about managing care costs that you can share with your employees to help them make smart, cost-effective decisions about their care.

Schedule preventive care services

Statistics from the Centers for Disease Control and Prevention (CDC) consistently show that many Americans don’t take advantage of preventive care services — even when they’re free. One report notes that fewer than 30 percent of adults ages 50 to 64 and less than half of adults age 65 and older were up to date on their core preventive services.

Most health plans now cover certain preventive care visits at 100 percent. Preventive care helps members to avoid health problems or catch them while they’re still relatively easy to treat, before they become serious and require expensive care. Some types of preventive care may not be covered 100 percent, and members may be required to use in-network providers.

Members should check their plans to see what’s covered, by reviewing their benefits booklet or calling their Member Service department.

Become a more informed consumer

A recent study showed that consumers tend to spend very little time researching health plans before they pick one. In fact, 79 percent of people spend less than an hour researching their health insurance options and more than half (56 percent) spent fewer than 30 minutes researching benefit options during their last open enrollment.

Members should research plans before enrolling. Before choosing a plan with the lowest monthly premium, they should think about whether that plan can provide the best coverage for any medical needs that may arise during the year and if the plan’s copay and deductible amounts are a good fit for their budget. 

Learn health insurance language

Understanding the definitions of key terms, such as deductible, coinsurance, copay, annual and lifetime maximums, and precertification will help members make informed plan decisions and better manage their out-of-pocket expenses. The Federal Healthcare has a comprehensive glossary of definitions.

Use online health tools and resources

Online tools and resources can help members understand medical costs and quality considerations. Members may find it helpful to check their insurer’s website for tools to estimate the cost of common medical services and procedures, compare medical facilities, and factor the cost and quality information into their decisions before they schedule an appointment. Some tools are able to base estimates on the member’s specific health plan, including up-to-date information about where the member stands in meeting their deductible — for an accurate, real-time picture of their out-of-pocket expenses. Members can compare health care costs at fairhealthconsumer.org/index.php.

Stay in the network

To get the most out of any health insurance plan, members should use their plan’s network providers. Health insurers negotiate contracts with providers (and entire provider networks). In return for the volume of business the plan members can provide, the providers agree to accept lower rates for their services. In contrast, providers generally charge higher rates to people without insurance or people who have insurance from companies with whom they don’t have a contract.

When a member goes out of network, the health plan usually covers a smaller percentage (or even none) of the cost of care.  Members should always use the health insurer’s provider search tool to determine if a provider is in-network, as this list can frequently change.

Use emergency rooms only for emergencies

Studies estimate that anywhere from 8% to 27% of visits to emergency rooms could have been handled by urgent care centers or other non-emergency facilities.

Even with a great health plan, going to the emergency room when it’s not necessary can be expensive. One source says that a non-emergency visit to the emergency room will cost $580 more than going to the doctor’s office.

For conditions that aren’t dangerous or life-threatening, members should check with their doctor’s office or go to an urgent care center to save money and time. Some services commonly done at hospitals — such as bloodwork and X-rays — can also be done in standalone labs or facilities. The cost of going to the hospital will almost always be higher. 

Be prepared and ask questions

When members have appointments scheduled with a doctor or other health care provider, they should be prepared to ask questions, including:

• How much will this cost?
• Do I have other treatment options?
• Will I need to see another doctor or get additional tests?
• Where should I have the tests done?
• Are those doctors in my plan’s network?
• How soon will I need to schedule those visits or tests?
• Is there a generic version of the medicine I need to take?

An informed member can help the provider make more appropriate decisions about their treatment plan.