Updated March 22, 2019: I’m afraid of going to the doctor. Not because I’m afraid of needles or the sight of blood or bad news, but because I never know how much it’s going to cost. For some things, avoiding the doctor isn’t a big deal – you don’t need to see the doctor every time you get the sniffles. But as anyone who’s tried to self-diagnose using WebMD can tell you, it can be hard to make the call between "safe to avoid the doc" and "you really need to see a doctor oh my god what is happening to your skin."
Trying to find out how much your doctor’s visit is going to cost before you go can be complicated. In this article, we’re going to walk through the two major parts of this calculation: your cost-sharing agreement with your health insurance company and the actual cost of the service. While that probably sounds incredibly boring, I promise I will throw in at least one GIF to make it worth your time.
Understanding your health insurance: cost-sharing edition
Health insurance, as you probably know, doesn’t pay for all of your healthcare costs. You can think of health insurance as a cost-sharing agreement between you and insurer. You pay a monthly premium, and in exchange, they pay a portion of your healthcare costs.
There are multiple factors that determine exactly how you and health insurance company will split the costs:
The deductible is the amount of money you need to pay out-of-pocket before your health insurance company starts contributing anything. (Here's a quick how-to on reading medical bills.)
For example, let’s say you’re seeing a doctor for the first time in a calendar year. As of this point, you haven’t paid anything out-of-pocket to visit a doctor. Your plan’s deductible is $500. The doctor’s visit costs you $350. You’ll pay that entire $350 by yourself because you haven’t hit that deductible yet, and now you only need to pay $150 for your insurance to kick in. The next time you pay $350 to see the doctor, $200 of it will be eligible for cost-sharing with your insurance company.
Not all healthcare services are subject to a deductible. Many insurers allow you to see a doctor or get a prescription for a fixed copayment, regardless of whether or not you’ve fulfilled your deductible.
Below, you’ll see an example of a fixed copayment for an office visit (and other services), as illustrated in an insurance company’s Summary of Benefits and Coverage document. The Summary of Benefits is your go-to document for understanding your health insurance benefits, and should be easy to find using Google.
A copayment is a fixed cost for a healthcare service.
For example, say your health insurance company has a copayment of $30 for doctor’s visits, regardless of whether or not you’ve fulfilled your deductible. When you visit the doctor for the first time in a calendar year, you’ll pay $30 for that visit. Other services that you receive during that visit, however, may be subject to a different cost-sharing agreement, or you may have to pay out-of-pocket if you have a deductible.
Health insurance companies usually use a combination of copayments and coinsurance to split costs with consumers.
Coinsurance is a percentage of a healthcare service that you will pay for.
For example, say you have a health insurance plan with no deductible, but instead has a 20% coinsurance for all services. When you visit the doctor for the first time in a calendar year, you’ll pay 20% of the total bill, no matter what services you receive during that visit. (Unless that service is free preventative care, but let’s not worry about that right now.)
Of course, you’ll only pay 20% up until you hit your out-of-pocket limit…
Your plan will have a maximum out-of-pocket limit, a number that represents the most amount of money you can spend out-of-pocket before your health insurance starts paying for 100% of the cost of covered services. This number is different for every plan, but there is a federally mandated maximum that this limit can be: in 2017, that maximum is $7,150 for individual plans and $14,300 for family plans.
Finding the specifics of your plan
When you purchased your health insurance plan, you probably received a big envelope in the mail. Inside of this envelope was a bunch of paperwork and maybe even a book that was full of information about your plan. If you’re anything like me, you recycled this paperwork. But if you’re smart, you kept this around, in a drawer or filing cabinet or stuffed in your closet.
Your plan’s specific details about deductible, copayment, coinsurance, and out-of-pocket limit will be in this paperwork. You may also be able to find the Summary of Benefits and Coverage document, which we discussed above, online by Googling your plan name. All plans are required to have this document. You can find your plan name on your health insurance card, which should hopefully be in your wallet.
Some of the details of your plan may even be on your health insurance card; for example, my health insurance card tells me the copayment for an office visit, a specialist visit, an urgent care visit, and an ER visit.
You can also call your health insurance company and ask them for these details, but then you have to talk to someone on the phone. If you are curious about how health insurance works in each state, check out our state-by-state guide to federal health insurance, or our state-by-state guide to Medicaid.
Once you have an understanding of what the details of your plan are, you can move on to the second major piece of calculating the cost of your doctor’s visit. But before that, your promised GIF...
The cost of your healthcare service
Finding out the cost of the healthcare service you are looking to get can be the most complicated part of this equation. There are certain universal truths – urgent care centers will usually cost less than an emergency room – but otherwise, healthcare costs can be all over the map.
Why? Because sometimes, you don’t know exactly what you need. If you’re reading this article, you’re probably not a doctor, and because you’re not a doctor, you have no idea what services you’re going to need before you go in.
Sure, you might have a guess: if you break your arm, you know you’ll probably need an x-ray and someone to put a cast around your arm. But if you go into the office thinking you have the flu, and in fact you have a more serious disease, such as meningitis or tuberculosis, do you know what services you’re going to need?
A key part of estimating your cost is making sure that you’re seeing an in-network provider. "In-network" means that your health insurance provider has negotiated a lower price for their services than if you didn’t have insurance. If you have an HMO, out-of-network providers aren’t covered at all, and if you have a PPO, they will cost significantly more than in-network providers.
You also need to check that everyone involved in your healthcare is in-network. For example, your in-network doctor may send your results to an out-of-network lab, leaving you with the full bill from the lab. Make sure your doctor works with in-network labs; call the lab yourself if you need to.
If you know what service you need, or have an idea what service you may need, shop around for the best price. The same procedure can cost wildly different amounts between two different providers, even if they’re in the same city, neighborhood, or even on the same block.
If you have a regular doctor, you can try contacting their office for a cost estimate before you go to the office. Ideally, your doctor’s office is as transparent as possible, but you may have a tough time getting a solid answer out of them. One reason for this is that doctors charge different fees for the same procedure depending on what insurance plan you have. These are referred to as negotiated rates, and they’re usually lower than what you would pay if you were uninsured. Feel free to call around to other doctors in your area to see if any of them give you a real number to work with. Here's a primer on negotiated rates.
You can also call your health insurance company to see if they have rates on file for specific services. If you know exactly what services you need, this may be your best option. Your insurance company may have a search tool that shows you providers in your area and what services cost at those locations. Check your insurer’s member online member portal.
You may not get a solid cost estimate. If you don’t, you can try going into the doctor’s office and requesting that they don’t perform any services that would cost you money (outside of the cost of the visit) without your consent. This can be a risky strategy – if they don’t follow your wishes, you’ll find yourself with a bill for a service you didn’t even realize cost you money.
If you can get a solid cost estimate, get out your calculator. Working backwards from the estimate, you should be able to use the information gathered about your insurance plan to figure out what your cost split with the insurer will be.
For example, let’s say you need a hearing test. According to Amino, a hearing test in the New York area for UnitedHealthcare enrollees is going to cost around $136. Let’s say your plan has a $0 deductible, a $30 copayment for doctor’s visits, and a 30% coinsurance for every other service. You’ll end up paying about $71 out-of-pocket for the hearing test: $30 for the visit and $40.80 for the hearing test.
This is a simple calculation, however, that may not account for all of the complexity of your plan. At the end of the day, you won’t know exactly what you’ll owe until you get your bill. Doing this calculation in advance, however, can help you prepare for out-of-pocket costs associated with utilizing healthcare.
Dealing with out-of-pocket healthcare costs
There are a few strategies for dealing with out-of-pocket healthcare costs.
One of the best is an HSA or FSA. Both of these special types of savings accounts help people put money aside for out-of-pocket healthcare expenses. The main benefit, however, is that money put in an FSA or HSA is tax-free, which can save you hundreds of dollars every year. Here's how to open an HSA.
You can also try telemedicine, which is a fancy word for talking to a doctor on the phone or through an app. Telemedicine is usually much cheaper than seeing a doctor in an office, and it can help you decide whether you just have a case of the sniffles or if you need to visit the nearest hospital now.
Your doctor may also have coupons available for deep discounts on lab services, prescriptions, and other peripheral costs. Coupons and other discounts may help you save over 50% on the cost of services. Ask your doctor what discounts are available.
If you find that you aren’t using your health insurance because you think that visiting the doctor is too expensive, it may make sense to find a new plan during open enrollment that has a different deductible, copayment, coinsurance, or out-of-pocket limit. Check out our health insurance comparison tool to find a plan that better matches you need.
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