Navigating Your Health Insurance

Updated 
August 31, 2015

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, consider getting help from a professional who specializes in healthcare management. You can find professional financial help from both your healthcare team and your insurance provider.

Your insurance provider has case managers who are available to help you get the most out of your insurance. If you ever need to negotiate the cost of healthcare with a doctor or hospital, or have questions about your policy, a case manager can help.

Your healthcare team may include a patient navigator or oncologyinfo-icon social workerinfo-icon. These members of your team are there to advocate in your best interests and communicate between your doctors and insurance provider. If you don’t 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 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 services that aren’t covered. These could include 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 medicineinfo-icon, such as acupunctureinfo-icon.
  • 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 charge and which require payment from you.
  • 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 comprehensive health plans that may cover more than your current plan for a higher monthly membership fee (also known as a premium). 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 does 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 or primary care doctorinfo-icon for a referralinfo-icon before you are able to see a specialistinfo-icon.
  • Specialist coverage: Sometimes a healthcare plan will cover certain services from one medical specialist and not another. 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 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. Someone at your doctor’s office usually handle getting pre-authorization for you. The process can take a few hours to a few days.
  • Prescriptions: Find out if prescriptions are covered and if you need to get name brand or genericinfo-icon medicines in order for insurance to cover costs.

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Article August 31, 2015