Many plans require you to choose a primary care physician (PCP). This doctor will coordinate your care and refer you to specialists as necessary. Even if your plan does not require you to choose a PCP, it is still important to schedule an appointment with an in-network doctor to establish yourself as a patient.

• To find a PCP, use the provider directory from your insurance company. If you selected a plan through the federal marketplace website, you can use healthcare.gov.
• You can change your PCP at least four times a year.
• If you have an HMO plan and have a chronic, disabling, or life-threatening illness you can apply to use a non-primary care physician specialist as your PCP.

Specialists are doctors with expertise in treating specific diseases and conditions. Whether your plan requires you to get a referral to see a specialist or not, the best way to find in-network specialists is to use your insurance company’s provider directory before you make an appointment. Plans must make the directory available online and update it as providers enter and leave the network. You can also request a paper copy.

• Use the directory to find specialists in your area that are accepting new patients.
• Use the directory to find out if specialists, hospitals, and other providers are in your network.
• Use the directory to find in-network hospitals with the lowest risk of balance billing from out-of-network doctors based at a hospital.
• If your network is inadequate you usually have the right to get out-of-network care at in-network costs.
• Make sure you get approval before getting non-emergency care from specialists because you might have to pay more if your plan doesn’t authorize the treatment.
• Check the Texas Medical Board’s website to look up info on doctors and other providers.
• Ask specialists for estimates of charges before you get care to compare what your insurance will pay. Ask for itemized billing statements after you are treated.

Your plan will only cover specific drugs and not all pharmacies will be in your network. You can save money by knowing where to get prescriptions filled and how your plan covers prescription drugs.

• Before you fill a prescription, check with your plan to find which pharmacies are in-network. In-network pharmacies will take your insurance information to ask for payment from your plan and will ask for your copayment when you pick up your prescription.
• Confirm with your plan what your copayment will be for the prescription.
• Find out if your medicine is covered by your plan and what your out-of-pocket costs will be for other drugs in the plan’s drug formulary list. This info will be in your policy or Evidence of Coverage (EOC) or on your insurance company’s website.
• Your plan might charge different amounts for generic drugs, brand-name drugs, and specialty drugs. You can ask your doctor if a generic or other lower cost drug is available.

Emergency care can vary in price and services depending on where you go. You can save time and money and get the care you need if you know the differences between emergency room (ER) facilities, such as traditional hospital ERs and freestanding ERs, and urgent care centers, and how to get info about your insurance company’s coverage network.

• How much you pay depends on where you go. Insurance companies pay for different parts of your bill based on where you go.
• Before you have an emergency, know where to go. You can save yourself money by choosing the right place. If an ER or urgent care center is in your network, you will pay less than if they are not in your network.
• “Accepting” insurance is not the same thing as “being in-network.” You need to know if the place accepts your insurance and is in your network.
• Health plans cannot require prior approval for emergency care.
• Verify your out-of-pocket costs with your plan.
• If possible, ask hospitals, ERs, and urgent care clinics for estimates of charges before you need or get care and always ask for itemized billing statements after you are treated.

Balance billing can occur when consumers get care or medical supplies from out-of-network healthcare providers, such as doctors, hospitals, or labs. Out-of-network providers do not have a contract with your health plan. If your health plan doesn’t pay the full amount of what the out-of-network provider charges, then the provider sends you a bill to for the remaining amount. This remaining amount is known as a balance bill. Senate Bill 1264, passed by the 86th Legislature prevents balance billing when consumers don’t have the option to see a provider in their health plan’s network.

To learn more about Balance Billing, visit our Balance Billing page.