No matter how you get your insurance -- through your employer, from a state exchange, from an agent or directly from an insurance company -- you're paying a bigger share of your health-care costs than you used to. Higher premiums are only part of the picture. Deductibles are rising, provider networks are shrinking, and insurers have been switching from fixed-dollar co-payments to coinsurance, based on a percentage of the cost of care.
Your out-of-pocket costs could rise significantly unless you learn some key strategies to become a better health care shopper. The following moves can help you save hundreds or even thousands of dollars.
1. Stay in Your Network
Many insurers are shrinking their networks and including fewer doctors and hospitals. "The most expensive health care mistake you can make is to go out of your health plan's network," says Jackie Aube, a senior vice-president of Cigna. The cost difference can be huge. Preferred provider organizations (PPOs) usually let you use out-of-network doctors but charge higher co-payments or coinsurance rates -- say, 50% for out-of-network care compared with 10% for in-network services. If your plan is a health maintenance organization (HMO), you may not have coverage at all for out-of-network providers except in an emergency.
The out-of-network base price may also be higher because the network's providers agree to the insurer's negotiated rate, but outside providers can charge more. You may also have a higher deductible for out-of-network care and a higher annual limit on your out-of-pocket expenses.
Before you visit a doctor or have a procedure, ask both your insurer and the providers if they're included in your plan's network. If you're having surgery, check on the surgeon, anesthesiologist and facility.
2. Find out About Super-Preferred Providers
Your health plan may provide extra incentives for you to use certain in-network providers or facilities. The UnitedHealth Premium designation program, for example, recognizes physicians that meet guidelines for providing high-quality, cost-efficient care, and you may pay lower co-payments or coinsurance rates if you use those doctors. Most health plans' search tools can help you find providers who participate in these special programs.
3.Save at Stand-Alone Radiology Centers
Different facilities charge vastly different prices for x-rays and tests. The average outpatient hospital cost for MRIs and CAT scans is $1,384 to $1,668, says Aube, but the average radiology center costs $445 to $725. And there can be a huge range between the highest and lowest cost in your area. For example, among all facilities within 25 miles of New York, the cost of a knee MRI ranges from $238 at a free-standing radiology facility to $2,191 at a local hospital, says Victoria Bogatyrenko, vice-president for innovation at United Healthcare. Most insurers have tools to help you compare the costs of x-rays and tests at different types of facilities in your area.
4. Ask Your Doctor About Cheaper Facilities
Your doctor may work at several hospitals or outpatient surgery centers. While the surgeon's charge will be the same, "the hospital's fees can vary by thousands of dollars," says Aube. The cost may be even less at an outpatient surgery center, even though the same doctor is performing the procedure. For example, the average cost nationwide for a colonoscopy, GI endoscopy or arthroscopy in a hospital is $2,548, but the average cost at an outpatient surgery center is $959, she says. Make sure the facility you choose is in your insurer's network.
5. Avoid the Emergency Room If You Can
Sometimes you can't avoid a trip to the emergency room. But you may be able to go to a much less expensive urgent care center or convenience care clinic for some types of care. Visit an urgent care center for conditions such as minor cuts, burns and sprains, fever and flu symptoms, joint or lower back pain, and urinary tract infections, says Aube. You may pay even less at a convenience care clinic at a supermarket, pharmacy or other retail store, where a clinician can treat you for sinus infections, rashes, earaches, minor burns and other routine medical conditions, she says. The cost varies by type of facility: The average cost nationwide of an emergency room visit is $1,553, compared with $135 for an urgent care center and $58 for a convenience care clinic. Find out ahead of time which nearby urgent care and convenience care clinics are included in your insurer's network.
6. Take Advantage of Telemedicine
Many health plans now offer 24-hour help lines staffed by doctors or nurses who can treat you by phone or online video chat. You can use this service for nonemergency conditions, such as cold and flu symptoms, nausea and vomiting, sore throat, earache, and sinus pain. A doctor will prescribe medications, if appropriate. The average telehealth consultation costs $40 to $50.
7. Switch to Generic Drugs
Generic drugs can cost as much as 80% less than their brand-name alternatives, says Aube. The lower list price makes a huge difference when you're in the plan's deductible period and paying the full price out of your pocket. And the coinsurance rates are usually lower, too -- often 10% to 15% of the cost for generics, 25% for preferred brand-name drugs, and 50% for nonpreferred brand-name drugs.
Some plans no longer cover certain brand-name drugs. For example, one popular health plan doesn't cover Lipitor, which costs $180.75 for a 30-day supply of 10 mg tablets. But the generic equivalent, atorvastatin calcium, would cost $13.92 under the same plan, says Jim Yocum, executive vice-president of DRX, which provides Web-based prescription-drug comparison services to health plans and employers. You may also get a good deal on generics at certain stores, such as Walmart and Target, which charge as little as $4 for a 30-day supply of certain drugs or $10 for a 90-day supply.
8. Keep an Eye Out for New Generics
The patents for several popular brand-name drugs -- Celebrex, Copaxone, Nexium, Actonel and Exforge -- are scheduled to expire soon, which will open the door for drug companies to manufacture generic alternatives. "It takes some time after patents expire for manufacturers of generics to receive approval from the U.S. Food and Drug Administration, make the drug and get supplies on drugstore shelves. Litigation can also delay expected patent expiration dates," says Yocum. You can look into generic alternatives now for Cymbalta, Maxalt, Maxalt MPT, Micardis, Micardis HCT, Twynsta and Xeloda, whose patents expired recently and for which generics are on the market, says Yocum. Most insurers have Web tools or apps to help you look up generic alternatives to your drugs.
9. Find Therapeutic Alternatives
Some brand-name drugs don't have a generic equivalent but may have a "therapeutic alternative." That means a medicine that is in the same class of drugs but is chemically a little different. For example, Diovan is a blood-pressure drug with no direct generic substitute. In one popular plan, the monthly cost for a 30-day supply of 80 mg tablets is $149.66. But you could spend $1 per month for a comparable dose of iosartan potassium, or $2 per month for irbesartan, or $20 for a monthly supply of Benicar, says Yocum. Ask your doctor about any switch that isn't a direct generic substitution.
10. Use Preferred Pharmacies
More health plans are introducing preferred pharmacies, which cost even less than regular in-network pharmacies. For example, the Humana Walmart Rx plan for Medicare Part D charges a $1 co-payment for a 30-day supply of certain generic drugs purchased at Walmart or Sam's Club (or a $0 co-payment through RightSource mail order), but the plan charges a $10 co-payment for the same drugs purchased at a nonpreferred network retail pharmacy. For pricier "Tier 4" preferred brand-name drugs (there are a total of five pricing tiers), you'd pay 39% coinsurance through Walmart, Sam's Club and RightSource but 50% coinsurance at nonpreferred network pharmacies.
11. Get Your Drugs Through the Mail
Mail-order pharmacies may provide a three-month supply of drugs for the same price as a one-month supply at a local pharmacy. Some plans require you to use mail order for maintenance drugs.
12. Split Your Pills
Ask your doctor if you can save money by cutting your pills. Your physician will have to write a new prescription for twice the strength and half the quantity, noting your intent to split the tablets, says United Healthcare's Bogatyrenko.
13. Know the Rules for Prescriptions
Many health plans are adding new hurdles that you must clear before you can get certain medications. For example, you might have to try step therapy (which requires you to try other medications first, if possible) or seek prior authorization (the insurer asks your doctor a detailed list of questions about your condition and your treatment before it will cover the drug). Understand the rules for getting your drugs covered, and get your doctor involved to help explain to the insurer why you need the medication or to file an appeal if it is denied.
14. Get a Prescription for Over-the-Counter Drugs
You can no longer use tax-free money from a flexible spending account or health savings account for over-the-counter drugs without a prescription (except insulin). To get reimbursed from your FSA or HSA, ask your doctor for a prescription for any medications you use regularly, such as pain relievers, allergy medications, anti-fungals and cough-and-cold medicines, says Jody Dietel, of WageWorks, which administers FSAs for employers.
15. Get Free Preventive Care
The Affordable Care Act requires all insurers to provide several kinds of preventive care without any cost-sharing from you, regardless of your deductible. Depending on your age, this rule may apply to blood-pressure, diabetes and cholesterol tests, mammograms and colonoscopies, flu shots, routine vaccines, well-baby and well-child visits, and other preventive services (see the preventive-care page at Healthcare.gov for details).
16. Avoid Preventive-Care Surprise Charges
The cost-free preventive care rule applies only to in-network services (it's not unusual for an anesthesiologist involved in a colonoscopy to be out-of-network, for example), and you may be charged extra if something comes up in the test that requires more investigation. Ask if all of the providers involved in a procedure are in your insurer's network. See Loopholes in Free Preventive Health Care for details.
17. Sign up for Medicare's Preventive Benefits
Medicare beneficiaries can also get many preventive benefits without co-payments or deductibles. The list includes mammograms, screenings for cervical and colorectal cancer, flu shots, pneumonia shots, and an annual wellness visit and personalized prevention plan. See Medicare's Preventive & Screening Services for a full list.
18. Get Extra Cash for Wellness Programs
Many employers who offered wellness benefits that weren't worth the effort have been beefing up their incentives recently. More than one-fourth of the large employers surveyed by the Kaiser Family Foundation offer gift cards, travel, merchandise or cash to workers who participate in wellness programs. The rewards can be substantial -- large employers surveyed by the National Business Group on Health added an average of $350 to employees' health savings accounts, or $500 to health reimbursement accounts, for participating in a wellness program.
19. Sign up for Special Health Programs
You may get extra cash or discounts on your premiums for taking a health-risk assessment or participating in a tobacco-cessation program. Or your employer may offer free weight-loss or stress-reduction programs. More than half the employers surveyed by the Kaiser Family Foundation offer special disease-management programs for diabetes, asthma, obesity or hypertension. Such programs may provide incentives for you to take your medications, visit your doctor and have regular tests.
20. Get Credit for Your Deductible
If you have a high-deductible plan, make sure you're getting credit toward the deductible for all of your care. Even if you're paying from your own pocket during the deductible period, file the claim so that you'll get the rate the insurer negotiated with the provider. Check your explanation of benefits to make sure you received credit toward meeting your deductible and your annual maximum out-of-pocket spending limit. And time your procedures carefully -- you may want to schedule them near the end of the year, after you've met your deductible, rather than in the new year, when the deductible resets.
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