5 of the Biggest Questions People Have About Health Care

Two people working in an office

The truth is that health care can be downright complicated. Between trying to understand premiums, deductibles, and copays to dealing with the rising cost of services, managing your health care can leave you asking a lot of questions. Not to worry, because we’ve got the answers to five of the most-asked questions about health care today.


“Services such as routine physical exams, blood pressure screenings, or cholesterol screenings are just a few examples of preventative care.”


What exactly is “preventative” care?

Preventative care is the care you receive to prevent illnesses and diseases, and consists of measures taken for disease prevention, as opposed to disease treatment. Under the Federal Health Care Reform Law, when you obtain these services from an in-network plan provider, they’re covered free of charge, with no member cost sharing. Services such as routine physical exams, blood pressure screenings, or cholesterol screenings are just a few examples of preventative care.

For a complete list of preventative services, visit www.healthcare.gov/coverage/preventive-care-benefits.


“When your doctor sends you for blood work, an MRI, or other tests, request that they send you to in-network facilities only.”


Why do I owe when I thought a service was covered?

The fact is, for some inpatient procedures and emergency department visits, the chance of getting a bill that you didn’t expect can be as high as 90% (JAMA Internal Medicine, 2019). Here are a few things you can do to lower your chances of receiving an unexpected charge for your next medical visit:

Do your homework before your tests or services
The minute you have a test or medical service scheduled, call your insurer to find out if it is covered and obtain the billing code (a six-digit code that determines cost). Then call your health care provider’s office and match the code with theirs. If they are different, you’ll have time to get to the bottom of the discrepancy before you have your test or service.

Make sure your health care providers and facilities are in-network
Out-of-network doctors and facilities can cost more. Ask if all the providers or specialists in the room for a procedure are in-network. And when your doctor sends you for blood work, an MRI, or other tests, request that they send you to in-network facilities only.

Shop around
Just like everything else you purchase, medical tests and procedures can vary in price. Harvard Pilgrim members can use services like Estimate My Cost to find providers and estimate the cost of services for surgery, inpatient, and outpatient procedures.

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What exactly is coinsurance?

Coinsurance is the portion of medical expenses that you’re responsible for after you’ve met your deductible. Basically, it’s a percentage of a covered service. So, if your health plan allows $100 for an office visit and your coinsurance is 20%, the amount you pay will be dependent on several factors.

Here are a few scenarios:

You’ve paid your required deductible.
This means you pay 20% of $100, or $20, and your insurance company pays the rest.

You haven’t met your deductible.
You pay the full $100.

The service isn’t covered by your health insurance plan.
You pay the full $100.

Doctor answering questions about health care to a patient


“The advantage of high-deductible plans is that they often have lower premiums, which can help save money in the long run.“


How does a high-deductible plan work? And how can an HSA help pay for a deductible?

A deductible is the amount you pay out of pocket for medical expenses before your insurance pays anything. High-deductible health plans (HDHPs) have deductibles of at least $1,350 for individual plans and at least $2,700 for family plans. For 2019, the out-of-pocket maximum, or the most you’ll have to pay in a year, should be no higher than $6,750 for an individual plan and $13,500 for a family plan.

The advantage of high-deductible plans is that they often have lower premiums, which can help save money in the long run. And, to help with the cost of out-of-pocket medical expenses, Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs) are cost-effective options. HSA contributions come from pre-tax dollars, so you can save a considerable amount on your medical expenses when you pay for them with your HSA. For example, if you’re in the 24% federal tax bracket, a $100 medical bill will effectively only cost you $76. You must have an HDHP to be eligible to contribute to an HSA, and to be eligible to receive any employer contributions to your HSA.

Harvard Pilgrim offers both HSAs and HRAs for people who want lower premiums but want to cost-effectively manage unexpected out-of-pocket bills.