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How you can make the most of your health plan

Emily Leland By Emily Leland

woman on laptop at kitchen table

You keep your insurance card in your wallet. You pay your premiums. But how much do you really know about your health plan?

Not all health plans play by the same rules. Knowing the type of plan you have ― and how to best use it ― could save you time and money. Let’s start by breaking down the differences among three common types of medical plans:

High-deductible health plans (HDHPs)

Among companies that offer health insurance, 25 percent offer only HDHPs. The plans have a minimum deductible of $1,300 for individual coverage and $2,600 for family coverage. (A deductible is the amount you pay for healthcare before insurance kicks in.) Note: You could have an HMO or a PPO that qualifies as an HDHP.

The high up-front costs of HDHPs can seem daunting, but the premiums are generally lower. (The premium is the amount you pay each month for your health plan coverage.) Keep in mind the following tips to make the most of your coverage. 

  • Get a health savings account. Pair your HDHP with a health savings account (HSA) to use pre-tax dollars to pay for medical expenses, even before you’ve met your deductible. Learn more about HSA-eligible expenses.
  • Take advantage of preventive care. Depending on your age, services such as mammograms, colonoscopies, annual well visits and vaccinations may be covered free of charge, even if you haven’t met your deductible. Learn more about preventive care.

Health maintenance organizations (HMOs)

HMOs offer lower premiums and a more limited network of doctors. Most HMOs only pay for services performed by in-network doctors. Here are three ways you can put your HMO to work.

  • Choose a primary care doctor you trust. In an HMO, all of your health services are funneled through your primary care doctor. So if you aren’t thrilled with your current doctor, it could be worth looking for someone new in your HMO network. Learn tips for finding a new doctor (video).
  • Understand how referrals work. If you need care from a specialist, like a dermatologist (skin) or cardiologist (heart), you’ll likely need a referral before your appointment. A referral is like a permission slip from your primary care doctor to see other types of health care providers.
  • Stay in network. In most HMOs, visits to doctors outside of your network aren’t covered by your insurance. Your primary care doctor usually can recommend specialists in your network.  

Preferred provider organizations (PPOs)

Preferred provider organizations, or PPOs, often have higher premiums than HDHPs or HMOs. In return, they offer lower deductibles than HDHPs and more flexibility than HMOs. Translation: You’ll probably pay more each month, but you can see any type of doctor you want without a referral. If you’re covered by a PPO, keep these things in mind.

  • Get to know the copay. If you go to the doctor and you have an HDHP, you’ll probably be billed for the full cost of the visit if you haven’t met your deductible. But with a PPO, you might have a copay. This is a set dollar amount for an office visit. For example, $25 for a primary care doctor visit, and $50 for a visit to a specialist. A copay usually is paid at the time of the appointment.
  • Don’t worry about referrals. PPOs give you the freedom to see different types of doctors, even if you don’t get the green light from your primary care doctor first.
  • Again, it’s best to stay in network. Unlike an HMO, most PPOs offer some coverage for out-of-network doctors. But going out of network still means higher costs, and not all services may be covered. Stay in network for lower copays and full coverage.

Tools you can use with any plan

Most insurance companies offer a few resources to help you make the most of your coverage, regardless of which type of plan you have. They include:

  • Network directories. Search tools like Aetna’s DocFind online provider directory, which allows you to find in-network doctors, hospitals and urgent care centers near you to help you avoid unexpected out-of-network costs.
  • Cost transparency tools. These compare estimated prices for a certain procedure or type of care, letting you shop around for the doctor or hospital that fits your budget. Aetna’s Member Payment Estimator also includes patient ratings and reviews along with cost information.
  • Health concierge services. Still not sure how your plan works? Most health plans offer a variety of ways to get in touch with customer support. Call the number on the back of your ID card, chat them up on your member portal, or tweet their social media support team, like @AetnaHelp. These experts can answer basic questions about your coverage, or help you navigate more complex claims issues.  

The next time you pull out your insurance card, take a look at your plan type. Understanding its ins and outs can make a big difference in your budget, and can help you be a more educated consumer the next time open enrollment rolls around.

About the author

Emily Leland is a writer and marketing professional living in Charleston, SC. Her goal is more exercise, less caffeine and finding balance as a working mom.