Find a primary care doctor in your network. (Your health plan may require you to select a primary care doctor). This doctor will be your first stop for checkups, minor injuries, or minor illnesses. For more serious injuries or illnesses, you may need a referral from your primary care doctor before you can make an appointment with a specialist.
- Before you make an appointment for health care, check to see if the doctor or health facility you plan to go to is in your plan's network, keep in mind networks can change.
- To get assistance finding a primary doctor in your network, visit your insurance company's website or call it directly. The number to call will be on your insurance card.
- If you use a doctor or health service outside your network, you likely will pay more for the services.
- Your network and co-pay amount are shown on your summary of benefits and coverage.
How Much Will It Cost?
Preventive care is free (if you use a doctor or provider in your network). Preventive care includes annual checkups, blood pressure and diabetes screenings, mammograms and colonoscopies, vaccinations and flu shots. Read more about preventive care on HealthCare.gov.
How much you pay for other health services varies by plan.
Out-of-pocket costs are your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, co-insurance, and co-payments for covered services plus all costs for services that are not covered.
There is a limit on the amount of out-of-pocket costs you have to pay each year. Once you reach this amount your health insurance begins to pay 100% of the allowed amount. Keep in mind all health care costs you pay out of pocket will not count toward this limit. For example, the out-of-pocket limit does not include your premium. Check your summary of benefits and coverage to see what is not included in the out-of-pocket limit for your plan. If you have questions, contact your insurance company.
The amount you must pay out-of-pocket for health care services covered by your plan before your plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you have met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Preventive care (such as annual checkups) is free, and does not count toward your deductible.
A fixed amount you pay for a covered health care service (for example, $25), usually when you receive the service. The amount can vary by the type of covered health care service.
Your plan may require a co-pay for each prescription filled.
Co-insurance is our share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if your plan's allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. Your plan pays the rest of the allowed amount.