FROM 

COVERAGE 

TO CARE

A Roadmap 

to Better 

Care and a 

Healthier

You

Congratulations on getting 

health coverage—it’s an 

important first step to better 

health and well-being! 

Coverage isn’t only important 

when you are sick, it’s helpful 

when you don’t feel sick. This 

roadmap explains what health 

coverage is, and how to use 

it to get the primary care and 

preventive services to help you and 

your family live long, healthy lives. 

How it works: 

Read the Roadmap from start to finish, or jump 

to a step for quick reference. You’ll find helpful 

examples throughout the Roadmap, and at the end 

of it you will find definitions for common health 

care terms and resources.

Start leading a healthier life now...

QUICK

REFERENCE

Your Roadmap to health

Step 1: Put your health first ......................................6

Why are prevention and health coverage important?

Step 2: Understand your health coverage..................8

What words should I know? How much will it cost me to get care?

Step 3: Know where to go for care ..........................16

Where do I go when I am sick? What is the difference between

the emergency department and primary care?

Step 4: Find a provider ............................................20

How do I find a provider that is right for me? What if I am

assigned a provider?

Step 5: Make an appointment..................................24

What information do I need and what questions should I ask

when making an appointment?

Step 6: Be prepared for the visit .............................26

What should I bring to the appointment? What questions

should I ask during the visit?

Step 7: Decide if the provider is right for you..........30

Is this a provider I can trust and work with? If not, what do I do?

Step 8: Next steps after your appointment ..............32

What do I do when I get home? How do I maintain my health?

Resources: Glossary and Links................................36
Your ROADMAP to health

1 Start 

here 

Put your health first

• Staying healthy is important for you 

and your family.

• Maintain a healthy lifestyle at home, 

at work, and in the community.

• Get your recommended health 

screenings and manage chronic 

conditions.

• Keep all of your health information in 

one place.

2

Understand your

health coverage

• Check with your insurance plan or 

state Medicaid or CHIP program to 

see what services are covered.

• Be familiar with your costs 

(premiums, copayments, 

deductibles, co-insurance).

• Know the difference between innetwork and out-of-network.

3

Know where to go for care

• Use the emergency department for a 

lifethreatening situation.

• Primary care is preferred when it’s not an 

emergency.

• Know the difference between primary care 

and emergency care.

Find a provider

4

4

• Ask people you trust and/or 

do research on the internet.

• Check your plan’s list of 

providers.

• If you're assigned a 

provider, contact your plan if 

you want to change.

• If you're enrolled in 

Medicaid or CHIP, contact 

your state Medicaid or CHIP 

program for help.

Visit marketplace.cms.gov/c2c for more information
5 Make an appointment

• Mention if you’re a new patient or 

havebeen there before.

• Give the name of your insurance plan 

and ask if they take your insurance.

• Tell them the name of the provider 

you want to see and why you want an 

appointment.

• Ask for days or times that work for you.

6 Be prepared for your visit

• Have your insurance card with you.

• Know your family health history and 

make a list of any medicines you take.

• Bring a list of questions and things to 

discuss, and take notes during your visit.

• Bring someone with you to help if you 

need it.

7 Decide if the provider is

right for you

• Did you feel comfortable with the 

provider you saw? 

• Were you able to communicate 

with and understand your provider?

• Did you feel like you and your 

provider could make good 

decisions together?

• Remember: it is okay to change 

to a different provider!

No

Yes

If you want to

change your

provider, return

to Step 4.

8

Next steps after your appointment

• Follow your provider’s instructions.

• Fill any prescriptions you were given, and take 

themas directed.

• Schedule a follow-up visit if you need one.

• Review your explanation of benefits and pay your 

medical bills.

• Contact your provider, health plan, or the state 

Medicaid or CHIP agency with any questions. 5
Put your 1 health first.

Staying healthy increases the chances you’ll be there for your 

family and friends for many years to come. Use your health 

coverage when you are sick and when you are well, to help you 

live a long, healthy life. While coverage is important, there’s no 

substitute for living a healthy lifestyle. 

Here’s what you can do to put your health and 

well-being first:

• Make time for physical activity, healthy eating, relaxation, and 

sleep.

• Get the preventive services that are right for you.

• Take an active role in your health. 

• Learn more about what you can do to stay healthy and share 

what you learn with your family and friends. 

WHAT IS A PROVIDER?

We use the term “provider” 

throughout this booklet to mean 

a health care professional. 

This may be a doctor, a nurse 

practitioner, behavioral health 

professional, or another health 

care professional you see. Your 

Primary Care Provider will be 

the provider you see the most, 

and they will get to know you 

and help you keep track of your 

health over time.

6
Why is preventive health care important?

Preventive services include health care like screenings, 

check-ups, and patient counseling that are used to 

prevent illnesses, disease, and other health problems, 

or to detect illness at an early stage when treatment is 

likely to work best. Getting recommended preventive 

services and making healthy lifestyle choices are key 

steps to good health and well-being. 

Having a provider who knows your health needs, and 

whom you trust and can work with, can help you:

• ensure you get the preventive services that are right 

for you

• make healthy lifestyle choices

• improve your mental and emotional well-being

• reach your health and wellness goals. 

Keep all of your health information in one 

place.

Use this booklet to keep track of your coverage 

information, your providers, and your health. It is 

important to keep this information up to date, and you 

may want to carry a copy with you for an emergency. 

Remember to protect your identity by keeping your 

personal information safe!

COST TIP 

You may be able to receive an annual visit or some 

recommended preventive services for free like the flu vaccine, 

obesity screening and counseling, and depression screening. 

Talk to your provider about what’s right for you, and use the 

Personal Health Checklist in the back of this booklet to track 

your results.

7
Understand your 2 health coverage.

Health coverage pays for provider services, medications, 

hospital care, and special equipment when you’re sick. It is 

also important when you’re not sick. Most coverage includes 

immunizations for children and adults, annual visits for women and 

seniors, obesity screening and counseling for people of all ages, 

and more for free. Keep your coverage by paying your monthly 

premiums (if you have them).

Insurance plans can differ by the providers you see and how much 

you have to pay. Medicaid and CHIP programs also vary from state 

to state. Check with your insurance company or state Medicaid 

and CHIP program to make sure you understand what services 

and providers your plan will pay for and 

how much each visit or medicine will 

cost. Ask them for a Summary of 

Benefits and Coverage document 

that summarizes the key features of 

the plan or coverage, such as the 

covered benefits, costsharing provisions, and 

coverage limitations 

and exceptions.

8
Here are explanations of some key health insurance words 

that you may hear. Other key words are explained in the 

back of this booklet. 

• A Network is the facilities, providers, and suppliers your 

health insurer has contracted with to provide health care 

services. 

• Contact your insurance company to find out which 

providers are “in-network.” These providers may 

also be called “preferred-providers” or “participating 

providers.” 

• If a provider is “ out-of-network” it might cost you 

more to see them.

• Networks can change. Check with your provider each 

time you make an appointment, so you know how 

much you will have to pay. 

• A Deductible is the amount you owe for health care 

services your health insurance or plan covers before 

your health insurance or plan begins to pay. 

For example, if your deductible is $1,000, your plan 

won’t pay anything until you’ve met your $1,000 

deductible for covered health care services subject 

to the deductible. The deductible may not apply to 

all services. 

• Co-insurance is your share of the costs of a covered 

health care service, calculated as a percent (for 

example, 20%) of the allowed amount for the service. 

You pay co-insurance plus any deductibles you owe. 

For example, if the health insurance or plan’s 

allowed amount for an office visit is $100 and you’ve 

met your deductible, your co-insurance payment 

of 20% would be $20. The health insurance or plan 

pays the rest of the allowed amount. 9
• A Copayment or copay is an amount you may be required to 

pay as your share of the cost for a medical service or supply, like 

a doctor's visit, hospital outpatient visit, or prescription drug. A 

copayment is usually a set amount, rather than a percentage. 

For example, you might pay $10 or $20 for a doctor's visit, lab 

work, or prescription. Copayments are usually between $0 and 

$50 depending on your insurance plan and the type of visit or 

service.

• A Premium is the amount that must be paid for your health 

insurance or plan. You and/or your employer usually pay it 

monthly, quarterly, or yearly. It is not included in your deductible, 

your copayment, or your co-insurance. If you don’t pay your 

premium, you could lose your coverage. 

• Out-of-pocket maximum is the most you pay during a policy 

period (usually one year) before your health insurance or plan 

starts to pay 100% for covered essential health benefits. This 

limit includes deductibles, co-insurance, copayments, 

or similar charges and any other expenditure 

required of an individual for a qualified 

medical expense. This limit 

does not have to include 

premiums or spending 

for non-essential health 

benefits.

10
The maximum out-of-pocket cost limit for any individual 

Marketplace plan for 2014 can be no more than $6,350 for an 

individual plan and $12,700 for a family plan.

• Explanation of Benefits (or EOB) is a summary of health care 

charges that your health plan sends you after you see a provider 

or get a service. It is not a bill. It is a record of the health care you 

or individuals covered on your policy got and how much your 

provider is charging your health plan. If you have to pay more for 

your care, your provider will send you a separate bill. 

11
1

2

4

5

6

7

Your Insurance Card or Other 

Document

12

3

You probably received a membership package with information 

about your coverage from either your health plan or your state 

Medicaid or CHIP program. Read this information because you 

will need it when you see a provider or if you call your insurance 

company to ask a question. If you can’t read or understand it, call 

your health plan or state Medicaid or CHIP program and ask them 

to explain it to you. 

You may have received a card or other document as proof of your 

insurance. Your card may look different from this one, but should 

have the same type of information. Some health plans don’t have 

cards, but you should have received this information in another 

way. If you didn’t receive a card, contact your health plan to see if 

you should have.

INSURANCE COMPANY NAME

Member Name: Jane Doe

Member Number: XXX-XX-XXX

Group Number: XXXXX-XXX

Plan type

Effective date

PCP Copay $15.00

Specialist Copay $25.00

Emergency Room Copay $75.00

Member Service: 800-XXX-XXXX

Prescription Group # XXXXX

Prescription Copay

$15.00 Generic

$20.00 Name brand
The following information may be included on your insurance card or another 

document from your health plan or state Medicaid or CHIP program.

Member name and date of birth. These are usually printed on 

your card.

Member number. This number is used to identify you so your 

provider knows how to bill your health plan. If your spouse or 

children are also on your coverage, your member numbers may 

look very similar.

Group number. This number is used to track the specific 

benefits of your plan. It’s also used to identify you so your 

provider knows how to bill your insurance.

Plan type. Your card might have a label like HMO, PPO, HSA, 

Open, or another word to describe the type of plan you have. 

These tell you what type of network your plan has and which 

providers you can see who are “in-network” for you.

Copayment. These are the amounts that you will owe when you 

get health care.

Phone numbers. You can call your health plan if you have questions about finding a provider or what your coverage includes. 

Phone numbers are sometimes listed on the back of your card.

Prescription copayment. These are the amounts that you will 

owe for each prescription you have filled.

1

2

3

4

5

6

7

13
The questions below can help you better understand your coverage 

and what you will pay when you get health care. If you don’t know 

the answers to these questions, contact your insurance plan or 

state Medicaid or CHIP agency.

• How much will I have to pay for a primary care visit? A specialty 

visit? A mental/behavioral health visit?

• Would I have to pay a different amount if I see an “in-network” or 

“out-of-network” provider?

• How much do I have to pay for prescription medicine?

• Are there limits on the number of visits to a provider, like a 

behavioral health provider or physical therapist?

• How much will it cost me to go to the Emergency Room if it’s not 

an emergency?

• What is my deductible?

• Do I need a referral to see a specialist?

• What services are not covered by my plan?

PREVENT HEALTH CARE FRAUD

If someone else uses your insurance card or member 

number to get prescription drugs or medical care, then 

they’re committing fraud. Help prevent health care 

fraud. 

• Never let anyone use your insurance card.

• Keep your personal information safe. 

• Call your insurance company immediately if you lose 

your insurance card or suspect fraud. 14
Here are some examples of how your insurance plan or state 

Medicaid or CHIP program might use the terms discussed in this 

section to cover your medical care. 

• All health plans must provide you with a Summary of Benefits and 

Coverage, which will have these examples showing how the plan might 

help pay for services.

• The actual costs and care will vary 

by your health care needs and your 

coverage. 

• Contact your health plan or state 

Medicaid or CHIP program to get 

more information.

Having a baby

(normal delivery)

• Amount owed to providers: $7,540

• Plan pays $5,490

• Patient pays $2,050

Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $700

Copays $30

Co-insurance $1,320

Total $2,050

Managing type 2 diabetes

(1 year of routine maintenance of a 

well-controlled chronic condition)

• Amount owed to providers: $5,400

• Plan pays $3,520

• Patient pays $1,880

Sample care costs:

Prescriptions $2,900

Medical equipment and 

supplies

$1,300

Office visits and procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $800

Copays $500

Co-insurance $580

Total $1,880

The numbers are not real 

costs and don’t include all key 

information. 

15

Source: https://www.cms.gov/CCIIO/

Resources/Files/Downloads/sbc-sample.pdf
Know where to 3 go for care.

NEED HELP? 

Call 9-1-1 if you have 

an emergency or lifethreatening situation.

Although you can get health care many different places, 

including the emergency department, it’s best for you to get 

routine care and recommended preventive services from a 

primary care provider. There are some big differences between 

visits to your primary care provider and visits to the emergency 

department, such as cost, time spent waiting for care, and follow 

up. The table on pages 18–19 helps you 

see the many ways in which going to 

your primary care provider is different 

from going to the emergency 

department. 

16
You can find primary care providers in offices, clinics, and health 

centers nationwide. Depending on your coverage and personal 

circumstances, you might find a primary care provider in:

• Private medical groups and practices

• Ambulatory care centers and outpatient clinics

• Federally Qualified Health Centers

• Community clinics and free clinics

• School-based health centers

• Indian Health Service, Tribal, and Urban Indian

Health Program facilities

• Veterans Affairs medical centers and outpatient clinics.

Primary care providers work with patients every day to ensure 

they get the right preventive services, manage their chronic 

conditions, and improve their health and well-being. Some 

places may offer services and supports that vary based on the 

needs of the community they serve, like community-based 

services and supports, mental health, dental, vision services, 

transportation, and language interpretation. 

KNOW BEFORE YOU GO

Not all types of providers and facilities take all insurance plans or 

types of coverage. Call the office before you go to make sure they see 

patients with your coverage. 

17
Differences Between Your Provide

18

Primary Care Provider 

You’ll pay your primary care copay, if you have one. This may

cost you between $0 and $50. 

You go when you feel sick and when you feel well. 

You call ahead to make an appointment. 

You may have a short wait to be called after you arrive

but you will generally be seen around your appointment time. 

You’ll usually see the same provider each time. 

Your provider will usually have access to your health record. 

Your provider works with you to monitor your chronic conditions

and helps you improve your overall health.

Your provider will check other areas of your health, not just the 

problem that brought you in that day. 

If you need to see other providers or manage your care, your 

provider can help you make a plan, get your medicines, and 

schedule your recommended follow-up visits or find specialists.

In some areas, you may be able to go to an Urgent Care Center. If Urgent 

out how much you will have to pay.
er’s Office and the Emergency Department 

Emergency Department

You’ll likely pay a copay, co-insurance, and have to meet your 

deductible before your health plan pays for your costs, especially if it’s not 

an emergency. Your copay may be between $50 and $150.

You should only go when you’re injured or very sick. 

You show up when you need to and wait until they can get to you.

You may wait for several hours before you’re seen if it’s not an 

emergency.

You’ll see the provider who is working that day.

The provider who sees you probably won’t have access to

your health records. 

The provider may not know what chronic conditions

you have.

The provider will only check the urgent problem you came

in to treat but might not ask about other concerns.

When your visit is over you will be discharged with instructions to 

follow up with your primary care provider and/or specialist. There may 

not be any follow-up support. 

 Care is available in your area, call your health plan before you go to find 

19
Find a 4 provider.

20

Choosing the right provider is one of the most 

important decisions you’ll make about your health 

care, and finding the right one can take a little work. 

Remember, you’re looking for a partner you can trust and work 

with to improve your health and well-being, so take time to think 

about what you need. Depending on how complicated your 

health care needs are, you may need to see more than one type 

of provider. Two common provider types are listed below.

A Primary Care Provider is who you’ll see first for most 

health problems. They will also work with you to get your 

recommended screenings, keep your health records, help you 

manage chronic conditions, and link you to other types of 

providers if you need them. If you’re an adult, your primary care 

provider may be called a family physician or doctor, internist, 

general practitioner, nurse practitioner, or physician assistant. 

Your child or teenager’s provider may be called a pediatrician. If 

you’re elderly, your provider may be called a geriatrician. 

In some cases your health plan may assign you to a provider. 

You can usually change providers if you want to. Contact your 

health plan for how to do this.

A Specialist will see you for certain services or to treat specific 

conditions. Specialists include: cardiologists, oncologists, 

psychologists, allergists, podiatrists, and orthopedists.
You may need a Referral (or get a specific instruction) from your 

primary care provider before you go to a specialist in order to 

have your health plan pay for your visit. For some services, your 

health plan may require you to first get Preauthorization—a 

decision by your coverage or health plan that a health care 

service, treatment plan, prescription drug, or durable medical 

equipment is medically necessary. This is also called prior 

authorization, prior approval, or precertification.

THE RIGHT PROVIDER 

It might take more than one visit to figure out if a 

provider is the right one for you.

21
Follow these four steps to find a provider you can 

trust and partner with to live a long, healthy life. 

1. Identify providers in your network. 

 • Call your insurance company or state Medicaid and CHIP 

program, look at their website, or check your member 

handbook to find providers in your network who take your 

health coverage. 

 • Tell them if you’re looking for something particular, like a 

provider who speaks a language other than English, or one 

who can accommodate your mobility or other functional 

impairment. 

 • If you already have a provider you like and want to keep 

working with, call their office and ask if they accept your 

coverage.

 • Keep in mind that most of the time, you’ll pay more to see a

provider who isn’t in your network than a provider who is in 

your network. 

2. Ask around.

 • Ask your friends or family if they have providers they like. 

 • Ask them what type of provider they are and what they like 

about them.

 • Sometimes you can look up providers on the Internet to see 

what other people in the community say about them.

22
3. Pick a provider.

Call the provider’s office and ask them 

questions to help you decide whom you 

want for your primary care provider. Some 

things you might think about include:

 • Is the provider accepting new patients, or patients with your 

health coverage? This may change during the year, so you 

should always ask.

 • Is the office close to your home or your work? How would 

you get there? 

 • Will the appointment times work with your schedule? 

 • Does the provider speak your language or have an 

interpreter available?

 • If you have limited mobility or another functional 

impairment, are you able to get into the provider’s 

office, access the exam tables and scales, and get key 

information in ways that meet your needs? 

 • Which hospital(s) does the provider work with and can you 

get there?

 • Is the office staff respectful and helpful? 

4. Give them a try!

Sometimes it takes more than one visit to figure out if a provider 

is the right one for you.

COST TIP 

Ask your plan if you need prior authorization before you visit your 

provider. If you don’t get preauthorization, you may be charged 

for things your health plan would have paid for.

23
Make an 5 appointment. 

When you make your appointment, have your 

insurance card or other documentation handy and 

know what you want.

Here are some things you should mention when you call and what 

you might be asked for. 

24

You should say: 

 • Your name and if you’re a new patient.

 • Why you want to see the provider. You might want to tell them 

you are looking to find a new primary care provider and ask for 

a “yearly exam,” or a “wellness visit,” or you might ask to come 

in because you have a specific concern, like the flu, allergies, or 

depression.

 • The name of your insurance plan or that you have Medicaid or 

CHIP coverage and make sure you have the correct information 

about which providers in the office are in your network. 

 • The name of the provider you’d like to see. You may have to wait 

longer for an appointment if you request a specific provider, so 

they might recommend another provider in your network if you’re 

feeling sick and need to come in sooner.

 • If you have a specific need—like translation or accessible medical 

equipment—ask whether the provider and the office can meet that 

need. If they cannot, ask if there’s another provider in the office 

who can. 

 • The days and times work for you. Some offices have weekend or 

evening appointments. 
You should also ask: 

 • If they can send you any forms you need to fill out before you 

arrive. This will save you time on the day of your visit.

 • If you need to bring anything to the visit, like medical records or 

current medications.

 • What to do if you need to change or cancel your appointment. 

Some offices charge a fee for missed appointments, late 

appointments, or appointments canceled less than 24 hours 

before they start.

25

What to expect when you 

make an appointment:

• They might ask you for 

information about you and 

your coverage, so have your 

card or other documentation 

handy when you call.

• You may have to wait a few 

weeks to get an appointment, 

especially if you’re a new 

patient. 

• If you call your provider’s 

office because you’re sick, 

you may be able to see them 

the same day. 
Be prepared for 6 your visit.

If this is your first visit to a new provider or you are using 

new health coverage, you will need to bring a few things 

with you. 

This will help your provider understand your health and 

lifestyle, and help you work together to improve your health 

and well-being during your visit and after you leave.

It is important to show up early for your appointment!

When you get to your provider’s office, check in with the front 

office staff. You may be asked to provide the following:

 • Insurance card or other documentation. 

 • Photo identification (e.g., driver’s license, government or 

school ID, passport, etc.).

 • Completed forms.

 • Your copay, if you have one. Ask for a receipt for your 

records.

The staff may ask you to fill out additional forms and to read 

over their privacy policy, which tells you how they will keep 

your information private. It is required by law.

COST TIP

If you need to change your appointment, contact 

your provider's office as soon as possible. Many 

providers charge a fee if you’re late, don’t show 

up for your appointment, or cancel less than 24 

hours before it starts. Most health plans will not 

pay these fees.

26
When you see your provider, it is helpful to share:

 • Your family health history and medical records, if you have 

them. 

 • Medications you are taking (and the bottles so your provider 

knows what dose you take). If you need a refill, ask for one.

 • Questions or concerns you have about your health—write 

them down so you don’t forget to ask.

You may want to bring someone with you, like a friend or 

family member, to help you talk to the provider.

KNOW YOUR RIGHTS

You should be treated with respect and your information kept 

private. If you’re not happy with how you were treated, ask to speak 

with an office manager or the provider and tell them your concerns. 

If things aren’t resolved, then this office may not be the right place 

for you.

27
Don’t be shy! 

Your provider is there to help you stay healthy. They can provide 

better care if you talk with them about your health and wellbeing and share any questions or concerns you have. If your 

provider says something you don’t understand, speak up! 

You should be able to answer these questions bef

you leave your provider’s office:

ore 

 • How is my health? What can I do to stay healthy? 

 • What do I do next? Do I need blood work or another test? If 

so, what is it for? When and how will I get the results? 

 • If I have an illness or chronic condition, what are my treatment 

options? What are the benefits and concerns for 

each option? What will happen if I don’t 

take care of it? 

 • If I need to take medicine, when do I 

take it and how much do I take? Are 

there any side effects? Is a generic 

available? 

28
ASK

Ask your provider for written materials you can take home and read, 

and if there’s a phone number you can call if you have questions. 

Don’t leave until all of your questions have been answered and you 

understand what to do next.

 • Do I need to see a specialist or another provider? Did I ask 

my provider for a suggestion? Do I need a referral? If so, do I 

have it? 

 • When do I need to come back for my next visit? 

 • What do I do if I have questions when I get home?

COST TIP

If you have to take medicine and 

you’re concerned about how much 

it will cost, tell your provider. They 

may have cheaper options for your 

medicine, or know of programs 

that help patients pay for their 

medicines. 

29
Decide if the provider 7 is right for you.

Your health and well-being are important and personal and 

you should have a provider that you can work with, trust, 

and feel comfortable talking to. 

Remember:

 • It’s important to find a provider that meets your needs.

 • If you’re not happy with your first visit, consider giving them 

another try. You can call the provider’s office and share your 

concerns. You may also be able to see another provider in 

that office.

COST TIP

If you were assigned a provider and you want to try 

someone else, call your health plan or go to their 

website to make that change. Make sure you choose 

a provider in your network or you will pay more for 

your care.

SPEAK UP 

If you’re not comfortable with your provider, say something! It is okay to ask for 

changes or to look for another provider. 

The right provider for you will meet your 

needs when you ask.

30
 After your first visit, think about these questions:

 • Did you trust your provider, and feel they cared 

about your health and about you as a person?

 • Did you feel that you were listened to and your health 

needs were addressed?

 • Did your provider answer your questions in a way that you 

could understand?

 • Did your provider use words you could understand, speak 

slow enough, pay attention to what you had to say, and speak 

in a way that made you comfortable?

 • Did you feel that your provider showed an interest in your 

concerns?

 • When they examined you and talked to you about your health, 

was the provider respectful of your opinions, culture and 

beliefs? Is this a place you’d feel comfortable going back? 

 • Did they provide any assistance you asked for, like an 

interpreter, translation or alternate form of written materials? 

Could you move around in the office and use the medical 

equipment without barriers? 

• Did you feel you were treated fairly by your provider and the 

office staff?

 • Could you contact your provider or the office staff if you 

needed to ask a question?

If you answered “Yes” to each of these questions, then you 

may have found a provider that’s right for you! 

If you answered “No” to any of these questions, ask yourself 

if you think the provider or staff would make changes if you 

spoke up. Sometimes asking for what you need is the best way 

to get it.

If you want to change providers, Go Back to Step 4 and look 

again at your list of “in-network” providers to find someone you 

can trust and work with.

No?

Yes?

31
Next steps after 8 your appointment.

Now that you have found a provider and 

had your first visit, where do you go from 

here? 

You’ll see your primary care provider for your 

recommended preventive care and for help managing 

chronic conditions, as well as when you feel sick. Even 

if you see a specialist for a specific service or condition, 

you’ll always come back to your primary care provider.

Ask your provider or their staff to notify you when your 

next visit or recommended health screenings should 

happen. Make an appointment for that visit as soon 

as you can and write it down someplace where you’ll 

remember it, or in the back of this book.

If you have questions or concerns between visits, 

call your provider. They can help answer questions 

you have about your health and well-being and 

adjust any medications you are taking. 

32
Follow through with your provider’s 

recommendations. For example, if they told 

you to go to a specialist, did you call for an 

appointment?

If not, is it because: 

You forgot. Do you need a reminder? Put it on your calendar, or use a 

smartphone app.

You were too busy. Remember to put your health first, and make 

time. Some providers offer extended weekday or weekend hours. 

You didn’t understand what you were supposed to 

do. Call your provider. Ask them questions until you understand, and 

take notes. Consider having someone you trust come with you to your 

next visit. 

You didn’t have the money. If you are worried you cannot afford 

your care, there may be ways to lower the cost. Your provider may be 

able to give you a cheaper medication, or you may qualify for programs 

to help with your costs. Ask about them.

You were scared. Many people are worried about getting bad 

news. Remember that by getting the preventive care that is right for you, 

your provider is more likely to find an illness or problem early and help 

you get better faster. 

You didn’t feel like you were treated with respect and 

dignity. If the way your provider or office staff spoke or acted made 

you not want to return or listen to them, speak up or consider changing 

providers. The right provider will treat you with respect and meet your 

language, cultural, mobility, or other needs.

33
Reading your Explanation 

of Benefits

After you visit your provider, you may receive an Explanations of 

Benefits (EOB) from your insurer. This is an overview of the total 

charges for your visit and how much you and your health plan will 

have to pay. An EOB is NOT A BILL and helps to make sure that 

only you and your family are using your coverage. You may get a 

bill separately from the provider. 

Here’s an example of an Explanation of Benefits

Your insurance plan’s or Medicaid or CHIP agency’s Customer 

Service Number may be near the plan’s logo or on the back of 

your EOB .

Explanation of Benefits 

(EOB)

Statement date: XXXXXX

Document number: XXXXXXXXXXXXXXXXXX

THIS IS NOT A BILL

Insurance

plan logo

Customer service: 1-800-123-4567

Member name:

Address:

City, State, Zip:

Subscriber number: XXXXXXXXX ID: XXXXXXXXX Group: ABCDE Group number: XXXXXX

Patient name:

Date received:

Provider:

Payee:

Claim number: XXXXXXXXXX

Date paid: XXXXXXXX

Claim Detail What your provider 

can charge you Your responsibility Total Claim Cost

Line 

No.

Date

of Service

Service 

DescriptionClaim 

Status

Provider 

Charges

Allowed 

Charges

CoPayDeductibleCoInsurancePaid by 

Insurer

What 

You 

Owe

Remark

Code

1 3/20/14–

3/20/14

Medical 

care

Paid $31.60 $2.15 $0.00 $0.00 $0.00 $2.15 $0.00 PDC

2 3/20/14–

3/20/14

Medical 

care

Paid $375.00 $118.12 $35.00 $0.00 $0.00 $83.12 $35.00 PDC

Total $406.60 $120.27 $35.00 $0.00 $0.00 $85.27 $35.00

1

5

2 3 4 6 7

Remark Code: PDC—Billed amount is higher than the maximum payment insurance allows. The payment is for the 

allowed amount.

34
Pay your bills and keep any paperwork. Some providers will not 

see you if you have unpaid medical bills. You may be able to go 

online to look up your own health information, such as screening 

and test results or prescribed medications. This can help you take 

charge of managing your health. 

APPEALS AND GRIEVANCES

If you have a complaint or are dissatisfied with a denial of coverage for 

claims under your health plan, you may be able to appeal or file a grievance. For questions about your rights, or assistance, you can contact 

your insurance plan or state Medicaid or CHIP program. If you think you 

were charged for tests or services your coverage is supposed to pay for, 

keep the bill and call the phone number on your insurance card or plan 

documentation right away. Insurance companies have call and support 

centers to help plan members. 

1 Service Description is a 

description of the health care 

services you received, like 

a medical visit, lab tests, or 

screenings. 

2 Provider Charges is the 

amount your provider bills for 

your visit. 

3 Allowed Charges is the 

amount your provider will be 

reimbursed; this may not be the 

same as the Provider Charges. 

4 Paid by Insurer is the amount 

your insurance plan will pay to 

your provider. 

5 Payee is the person who will 

receive any reimbursement for 

over-paying the claim. 

What You Owe is the amount 

the patient or insurance plan 

member owes after your 

insurer has paid everything 

else. You may have already paid 

a portion of this amount, and 

payments made directly to your 

provider may not be subtracted 

from this amount.

Remark Code is a note from 

the insurance plan that explains 

more about the costs, charges, 

and paid amounts for your visit.

Contact your health plan if you have questions about your EOB. 

6

7

35
GLOSSARY

Appeal

An appeal is the action you can take if you disagree with a coverage or 

payment decision by your health plan. You can appeal if your health plan denies 

one of the following:

• Your request for a health care service, supply, or prescription drug that you 

think you should be able to get

• Your request for payment for health care or a prescription drug you already 

got

• Your request to change the amount you must pay for a prescription drug

• You can also appeal if you’re already getting coverage and your plan stops 

paying.

Co-insurance

An amount you may be required to pay as your share of the cost for services 

after you pay any deductibles. Co-insurance is usually a percentage (for 

example, 20%).

Copayment

An amount you may be required to pay as your share of the cost for a medical 

service or supply, like a doctor’s visit, hospital outpatient visit, or prescription 

drug. A copayment is usually a set amount, rather than a percentage. For 

example, you might pay $10 or $20 for a doctor’s visit or prescription.

Deductible

The amount you owe for health care services your health insurance or plan 

covers before your health insurance or plan begins to pay.

Emergency Services

Evaluation of an illness, injury, symptom, or condition so serious that a 

reasonable person would seek care right away and treatment to keep the 

condition from getting worse.

Resources

36
Excluded Services

Health care services that your health coverage or plan doesn’t pay for.

Explanation of Benefits (or EOB) 

A summary of health care charges that your insurance company sends you 

after you see a provider or get a service. It is not a bill. It is a record of the 

health care you or individuals covered on your policy got and how much your 

provider is charging your insurance company. 

Formulary

A list of prescription drugs covered by a prescription drug plan or another 

insurance plan offering prescription drug benefits. Also called a drug list.

Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.

In-network Co-insurance

The percent (for example, 20%) you pay of the allowed amount for covered 

health care services to providers who contract with your health insurance or 

plan. In-network co-insurance usually costs you less than out-of-network coinsurance.

In-network Copayment

A fixed amount (for example, $15) you pay for covered health care services 

to providers who contract with your health insurance or plan. In-network 

copayments usually are less than out-of-network copayments.

Network (also referred to as in-network)

The facilities, providers, and suppliers your health insurer or plan has 

contracted with to provide health care services.

Out-of-network

A provider who doesn’t have a contract with your health insurer or plan to 

provide services to you. You’ll pay more to use them.

37
Out-of-network Co-insurance

The percent (for example, 40%) you pay of the allowed amount for covered 

health care services to providers who don’t contract with your health insurance 

or plan. Out-of-network co-insurance usually costs you more than in-network 

co-insurance.

Out-of-network Copayment

A fixed amount (for example, $30) you pay for covered health care services 

from providers who don’t contract with your health insurance or plan. Out-ofnetwork copayments usually are more than in-network copayments.

Out-of-pocket Maximum

The most you pay during a policy period (usually one year) before your health 

insurance or plan starts to pay 100% for covered essential health benefits. The 

out-of-pocket maximum includes the yearly deductible and may also include 

any cost sharing you have after the deductible. For most health plans for 2014, 

the highest out-of-pocket maximum for an individual is $6,350 and $12,700 for 

a family. These numbers will rise in 2015.

Preauthorization

A decision by your health insurer or plan that a health care service, treatment 

plan, prescription drug, or durable medical equipment is medically necessary. 

Sometimes called prior authorization, prior approval, or precertification. Your 

health insurance or plan may require preauthorization for certain services 

before you receive them, except in an emergency. Preauthorization isn’t a 

promise your health insurance or plan will cover the cost.

Resources

38
Premium

The periodic payment to an insurance company or a health care plan for health 

or prescription drug coverage.

Preventive Services

Routine health care that includes screenings, check-ups, and patient 

counseling to prevent illnesses, disease, or other health problems or to detect 

illness at an early stage, when treatment is likely to work best (this can 

include services like flu and pneumonia shots, vaccines, and screenings like 

mammograms, depression/behavioral health screenings, or blood pressure 

tests, depending on what is recommended for you).

Primary Care Provider

The doctor you see first for most health problems. He or she makes sure you 

get the care you need to keep you healthy. He or she also may talk with other 

doctors and health care providers about your care and refer you to them. In 

many health plans, you must see your primary care doctor before you see any 

other health care provider.

Specialist

A physician specialist focuses on a specific area of medicine or a group of 

patients to diagnose, manage, prevent, or treat certain types of symptoms and 

conditions. A non-physician specialist is a provider who has more training in a 

specific area of health care.

39
HELPFUL LINKS

Getting Coverage

How to get coverage through the 

Health Insurance Marketplace

https://www.healthcare.gov/blog/4-

steps-to-getting-covered-in-the-healthinsurance-marketplace/ 

How much will health insurance 

cost?

http://kff.org/interactive/subsidy-calculator/

What plans are available in my 

area?

https://www.healthcare.gov/find-premium 

estimates/

Contact Your Insurance 

Plan

Contacting your health plan’s 

customer service phone number

http://marketplace.cms.gov/outreach-and 

education/contact-health-plan.pdf

Value of Prevention

Understanding prevention and 

the Affordable Care Act

https://www.healthcare.gov/prevention/

Finding a Provider

Reviews and ratings of local 

providers

http://www.healthgrades.com/

Planning Your First Visit

Steps to help you plan your first 

visit

http://www.ahrq.gov/patients-consumers/

patient-involvement/ask-your-doctor/

questions-before-appointment.html

Questions to Ask Your 

Provider

Topics and questions to discuss 

with the provider during your visit

http://www.ahrq.gov/patients-consumers/

patient-involvement/ask-your-doctor/

questions-during-appointment.html

Patient-Provider 

Relationship

The importance of 

communicating with your 

provider 

http://www.ahrq.gov/patients-consumers/

patient-involvement/ask-your-doctor/

videos/index.html

Tracking Your Medicine

Patient guide and wallet card to 

keep a record of all medications

http://www.ahrq.gov/patients-consumers/

diagnosis-treatment/treatments/safemeds/

yourmeds.html

Resources

40
Notes

41
Personal Health Checklist

This checklist has some common screenings and preventive services that 

on your age, gender, and pregnancy status by going to www.healthfinde

Protect Your Identity: Keep your personal information safe, whether it is 

dispose of your personal information securely, especially your Social Secu

42

Health Screening Date Result 

Height and Weight

__________________

Body Mass Index (BMI) 

__________________

Blood Pressure

__________________

Cholesterol

__________________

Vaccinations and Immunizations

__________________

Cervical Cancer Screening 

(sometimes called a Pap Test)

Colorectal Cancer Screening 

(colonoscopy) 

Breast Cancer Screening 

(mammogram)

Other Screenings 

Recommended for Me
 Notes (Is this result good or bad? What should I do about it?)

t you may receive. You can make a checklist specific to your needs based 

.gov.

n paper, online, or on your computers and mobile devices. Store and 

rity number.

r

 o

u

43
YOUR IMPORTANT 

INFORMATION

This Roadmap 

Belongs To ________________________________________________

Health Plan Name __________________________________________

Policy Number ____________________________________________

Group Number _____________________________________________

Health Plan Phone Number__________________________________

Primary Care Provider ______________________________________

Other Providers ____________________________________________

Pharmacy _________________________________________________

Allergies___________________________________________________

Emergency Contact ________________________________________

Medications _______________________________________________

___________________________________________________________

Other _____________________________________________________

___________________________________________________________

Protect Your Identity: Keep your personal information safe, 

whether it is on paper, online, or on your computers and mobile 

devices. Store and dispose of your personal information securely, 

especially your Social Security number.

Cut here

44

marketplace.cms.gov/c2c

CMS Product No.

11813 June 2014