This article appeared in the Winter 2018-19 edition of The Classroom Teacher.

With health insurance premiums and the cost of medical care continuing to rise, you should make sure you are familiar with your health insurance coverage so that you can use it correctly and cost-effectively.

Learn about balance billing. Balance billing is one of the most important, potentially most devastating, and least understood aspects of health insurance coverage. Medical providers can bill patients directly for costs not covered by insurance. If you receive services from an out-of-network doctor (even unknowingly) you can get a surprise bill charging you thousands of dollars. Not only can you be on the hook for your coinsurance percentage (for example, you may have to pay 40 percent of expenses to an out-of-network doctor, compared to 20 percent for in-network) but since an out-of-network provider doesn’t have arrangements with your insurer regarding costs, you can be billed for amounts beyond what the insurance company considers “reasonable and customary.”

If you are enrolled in a plan that uses a preferred network of doctors and hospitals, the first rule of thumb is to do what you can to ensure that you stay within the network. A common example of unanticipated billing comes from the use of an out-of-network anesthesiologist during surgery. You should be proactive in working with your physicians and hospitals to ensure that you are treated by in-network doctors to the greatest extent possible.

If you have coverage through a preferred provider organization (PPO), the Employees Retirement System (state employee health insurance) or TRS, and receive a surprise bill of more than $500, you may be eligible for a mediation process established through the Texas Department of Insurance (

Understand urgent care vs. hospital emergency rooms vs. freestanding facilities. In an emergency situation, you may not have time to figure out the best and most cost-effective place to go for medical help, so it’s a good idea to look into your options now. Many Texas towns have an urgent care center of some type on virtually every corner. But not all such facilities are the same, and your insurance coverage is likely to vary considerably depending on where you go. The examples below refer to the TRS-ActiveCare 2 plan, but other plans will have different costs, so be sure to (a) check your own plan and (b) identify the types of facilities near you so that you can be prepared if an emergency arises.

Urgent care facilities are associated with hospitals, and an urgent care center that participates in your provider network will likely be your least expensive option. Urgent care is specifically for serious but not life-threatening situations, such as broken bones or cuts requiring stitches. For enrollees in TRS-ActiveCare 2, the cost of an in-network urgent care visit is a $50 copay.

Hospital emergency rooms are necessary for life-endangering situations, and patients should not hesitate to call 911 or go to any hospital or doctor immediately. A visit to a traditional emergency room associated with a hospital in your network for a TRS-ActiveCare 2 enrollee would cost a $250 copay plus 20 percent coinsurance after your deductible.

Freestanding ERs are not attached to a hospital and may be privately owned. In addition to higher costs (under TRS-ActiveCare 2, you would be charged a $500 copay plus 20 percent coinsurance after your deductible), if you need hospital care you would have to be transferred to a hospital, costing you time and money.

Take advantage of your plan’s free services. Most preventive medical services are fully covered by health insurance plans. Using these services benefits both you and your insurance company, as potential medical problems are more likely to be caught earlier.

Few people enjoy medical procedures, but always start with your free annual wellness visit and follow your doctor’s advice on immunizations and screenings such as cholesterol testing, mammograms, and colonoscopies. NOTE: In many cases screening procedures are billed as “diagnostic” rather than “preventive” if a condition is suspected or has already been detected. For example, your doctor may check your blood sugar as part of an overall routine blood workup; this would be preventive and the test would be fully covered. If you already have been diagnosed with diabetes, the blood sugar check is diagnostic and your deductible/copay/coinsurance would apply.

Don’t hesitate to question and appeal medical bills. The medical profession is notorious for inaccurate billing and you may find that you have been egregiously overcharged, or billed for services or items not provided. Review your itemized bills, and let the provider’s billing department know when you find a mistake. The hospital’s patient advocate may be of help you to at this point.

You may be able to negotiate excessive charges directly with the facility, or appeal to the insurance company who can work on your (and their) behalf. If your bill is unusually large or your situation is complicated, you may find it worth your while to hire a professional medical billing advocate.

Utilize the expertise at TRS and your insurance company. Even if you’re not enrolled in TRS-Care or ActiveCare for your insurance coverage, the information in TRS’s newsletters can help you navigate your own coverage better. Recent articles from TRS address not only issues such as those above, but recommendations for improving your overall health through better nutrition and stress reduction.

Your insurance company likely has a wealth of information and many resources available to help you save money and maximize your health care, from the basics like provider networks and preferred prescription drugs to cost estimators, 24-hour nurse hotlines, free weight loss programs, discounted gym memberships and more.