Types of Care
Preventive and Wellness Services: Coverage and Costs
Preventive services, such as vaccines and screenings, can help you avoid certain diseases and catch others in their early stages, to limit the harm they can cause. Wellness services, such as weight management and stress reduction, can help you adopt a healthy lifestyle. To find out what preventive and wellness services are recommended for you or your family, talk to your doctor and see the Centers for Disease Control and Prevention (CDC) Prevention Checklist.
Federal law requires most health insurance plans to provide certain preventive services at no cost to you. The services are categorized as being for all adults, women or children. For full details, including guidelines about life stages when you should receive the services, see HealthCare.gov’s information here. When using these services, remember these points:
Get the service from a doctor or other provider in your health plan’s network.
Related services (such as a biopsy performed as a result of a screening test) may not be free.
Some older plans may be exempt from the law.
The law doesn’t require health plans to cover every kind of preventive service for free, just the specified ones.
Many employers offer workplace wellness initiatives, such as dietary counseling and on-site exercise programs. Some employers may offer financial incentives or other rewards to employees who take part in wellness programs. Ask your employer if such a program is offered at your workplace.
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Emergency Care and Urgent Care
Your plan’s rules and costs may differ for some types of care. Knowing these rules can help you control your costs and get the right care in the right setting.
Emergency care. Many plans cover some part of the cost of emergency care for sudden, serious sicknesses or injuries. They may cover emergency care even if you are outside the plan’s network. Once your condition is stable, you will often be moved to a doctor or hospital in your plan’s network for further care.
You will often pay a copay, which is sometimes waived if you are admitted to the hospital. Keep in mind that most plans only cover visits to the emergency room (ER) for “true” emergencies. If you visit the ER for non-emergency care, you could have high out-of-pocket costs.
Urgent care. When you need care quickly for an illness or injury that is not a “true emergency,” you can visit an urgent care center. These centers offer care after hours and on weekends, when your family doctor may not be available. But, they are not equipped to deal with major traumas or health problems.
Most health plans have urgent care centers in their networks. Your copay or coinsurance for an urgent care visit will often be lower than for an ER visit.
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In a serious emergency or one that threatens your life, seek care first. Call your insurer once your health problem is stable.
Many insurers have 24-hour helplines for members. If you’re not sure whether to go to the ER or some other setting, call and ask.
Visit your plan’s website to find urgent care centers in your network.
Mental and Emotional Health
Our mental and emotional health is a vital part of our well-being. If we don’t get the help we need, mental and emotional health problems can hurt our relationships with our family and friends, our jobs and even our communities. Those health problems may include depression, anxiety, bipolar disorder, schizophrenia, drug and alcohol abuse and attention deficit disorder, among others.
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires most plans that cover mental health to offer the same level of coverage for such health problems as they do for medical conditions. That includes costs like copays, deductibles and coinsurance, as well as treatment limits. Those limits may include number of visits, inpatient days of coverage and how often you can get treatment.
Does your plan include mental health services and cover out-of-network medical care? Then, it must also cover out-of-network mental healthcare. But, you may still need to follow plan rules to avoid high out-of-pocket costs. Those rules may include having your insurer approve services in advance, or getting a referral from your primary care physician (PCP).
Before getting mental healthcare:
Find out what your plan covers. Find out whether there are any limits or restrictions. See how much you may have to pay for care in and outside of your plan’s network.
Ask if you need a referral from your PCP before seeking mental health or substance abuse treatment. Ask if you need pre-approval from your plan.
Once you start treatment, keep track of your visits and inpatient days. That way, you’ll know when you are close to reaching your plan’s limits.
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Anesthesia is used to block pain, relax you or control how awake you are. It is used during surgery or other complex procedures. You may need anesthesia even if you’re not in an operating room. An anesthesiologist may manage pain during an acute sickness or a condition like cancer. He or she might also treat you when you give birth or for outpatient tests like endoscopies.
Suppose you’re planning a procedure that calls for anesthesia. Then, it’s important to know how these services work. That’s because they are often billed and paid separately from your procedure. Anesthesia providers may not be connected with your hospital or your doctor’s practice. That can leave you with high out-of-pocket costs.
Anesthesia is often provided by an anesthesiologist. But, a certified registered nurse anesthetist (CRNA) or anesthesiologist assistant (AA) can also administer anesthesia.
Understanding anesthesia costs. The price of anesthesia is based on several things. They include the difficulty of the procedure, the time it took and “modifying factors” like the patient’s health. The formula for anesthesia charges also includes a dollar value that depends on your location.
Avoiding high out-of-pocket costs. Before your procedure, make sure to find out:
Whether the anesthesiologist who will provide your care is in your plan’s network;
How much she or he will charge; and
How much your plan will cover.
If the anesthesiologist is not in your network, you can ask for a provider who is.
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Receiving Care from Accountable Care Organizations
An Accountable Care Organization (ACO) is a group of doctors or hospitals who have agreed to work together to coordinate and improve their patients’ care. Coordinating care means that all of the people treating you know your medical history and treatment plan. In some cases, all of your medical information will be stored in a personal electronic health record. You, your doctors and other providers can share that record. That way, everyone has a full picture of your health. That helps you avoid getting the same screenings or tests twice. It also makes sure you get preventive care like flu shots or, if you have diabetes, regular blood tests.
An ACO is not a type of health plan. It is just a way of organizing your care within the plan you already have. Your doctor or insurer may invite you to join an ACO. You also may ask your plan whether you are already in an ACO, and if you are not, whether you can join one. There should be no extra cost for using an ACO. You may even get rewards for meeting certain “good health” guidelines.
In an ACO, doctors and hospitals are paid more if they meet specific quality goals. The goals may involve preventive care and taking care of patients with long-term health issues like diabetes or heart disease. Patients in an ACO may be able to visit providers outside the organization for care. But, if you are in a private plan, there may be higher costs for going outside this “network within a network.” If you are in a Medicare ACO, you can still see any doctor who accepts Medicare without paying more.
If you are in an ACO:
Talk to your primary care physician (PCP) about your care and understand who is in your ACO network.
Ask your plan if you will pay more to visit doctors outside the ACO, even if they are in your plan’s broader network.
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Getting Care from a Medical Home
A medical home is a type of doctor’s practice that uses a team to focus on the “whole person.” It is sometimes called a patient-centered medical home (PCMH). The team is often run by one or more primary care physicians (PCPs), or sometimes nurse practitioners. The team coordinates all of your care needs. Coordinating care means all of the people treating you know your medical history and treatment plan. They can work together to get you the care you need and avoid providing services you don’t need.
A medical home is not a type of health plan. It is similar to other health networks that aim to coordinate patient care better, such as Accountable Care Organizations (ACOs). If the providers are in your plan’s network, there is no extra cost to get care through a medical home. Medical homes can be good for many types of patients. They may be especially helpful for patients who need ongoing care, like those with chronic health problems such as asthma, heart failure or diabetes.
One key goal of a medical home is giving “patient-centered care.” That means working closely with you and your family to make sure you have a say in your treatment.
If you do not know whether you are already in a medical home, ask your PCP. If you would like to join one, ask your insurer for a list of medical homes in the plan’s network. Or, look here for providers in your state who meet the PCMH standards of the National Committee for Quality Assurance (NCQA).
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