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Navigating Your Health Insurance

Updated April 24, 2014

Understanding your health insurance plan and what it covers is an important part of managing the costs of any long-term illness. Knowing the terms of your benefits will help you plan ahead for out-of-pocket expenses and help you get the most coverage possible for the tests, treatments and procedures you need. Sharing what you know about your health insurance with your doctors will help them recommend medical care that is covered by your health plan.

Ask for Professional Help

No one expects you to handle your treatments or treatment planning on your own. Before you make any decisions about next steps, you may find it helpful to get help from professionals who are there to make paying for your healthcare easier. You can find professional financial help from both your healthcare team and your insurance provider.

  • Your insurance provider has case managers working for them who are available to help you get the most out of their insurance. A case manager can not only answer any questions you have about your policy, but can also be a liaison between you and your doctors or hospital administrators if you ever need to negotiate the cost of care.
  • Your healthcare team may include a patient navigator or oncology social worker. These members of your team are there to advocate in your best interests and communicate between your doctors and insurance provider. If you do not already have a patient navigator or social worker on your healthcare team, ask to add one.
  • Your employer may have someone on staff in the human resources department whose job it is to manage complex cases that involve medical benefits. If you get your insurance through an employer, contact human resources to see what support they can provide.

Find Out What Your Plan Covers

Insurance providers offer a variety of plans with different coverage options. Call your provider and ask for an up-to-date copy of your plan and make a list of the following:

  • Any exclusions or items not to be covered. These are specific treatments, specialists, prescriptions, etc., that your insurance provider will not cover as stated in the plan. For example, many plans do not cover complementary medicine.
  • Any out-of-pocket expenses like co-payments or deductibles. Some providers may require these payments from you, while others may not. Note which services are free of charges and which require them.
  • Any co-insurance requirements. Co-insurance is similar to a co-pay, but is usually a percentage of the total cost of treatment instead of a fixed dollar amount. This can make planning harder and treatment more expensive. You may be required to pay a co-pay and a co-insurance amount for certain care.

Making a list of costs will allow you to budget for your medical expenses and stay in control of your finances. Many insurance providers and employers offer other, more comprehensive health plans that may cover more than your current plan, for a higher monthly membership fee. If you find that your expenses are high with your current plan, consider whether switching to another plan might be more cost-effective.

Explore Plan Limitations and Requirements

Health plans differ based on what employers choose to offer, what each plan covers and does not cover, and how you need to proceed in getting treatment. To keep your costs as low as possible, explore the following topics to fully understand your plan’s requirements.

  • Referrals and specialists: Some health plans require you to see your general doctor for a referral before you are able to see a specialist.
  • Specialist coverage: On occasion, a health care plan will cover medical visits with, and services received from, some medical specialists and not others. Find out which specialists participate with your plan.
  • In-network vs. Out-of-network providers: Many insurance plans require insurance holders to see doctors in their “network” in order to pay the lowest possible fees. If you see an out-of-network provider, you will likely have to pay a higher co-pay or the whole cost of treatment. HMO, PPO and POS plans may all recognize in-network providers and out-of-network providers, but depending on your plan the cost of seeing an out-of-network provider will vary. Stay in network, if possible.
  • Pre-authorization: Some insurance providers require you to gain their approval for a treatment or diagnostic test before receiving either so they can determine if they are medically necessary.
  • Prescriptions: Find out if prescriptions are covered and if you need to get name brand or generic medicines in order for insurance to cover costs.

Learn more about lead reviewer Joanna L. Fawzy Morales, Esq, and the other providers who helped us write this page in our  Guide to Understanding Financial Concerns, 1st ed., 2010.