How to Figure Out What Health Insurance Covers

What does your health insurance plan cover?

Figuring out your health insurance plan can cause stress. You can work with your insurance company to help you understand your plan, what it covers, and where to find care.

Review your insurance plan documents to understand:

• Benefits coverage
• Providers who are in your network. In-network providers are doctors, hospitals, and other care providers who have a contract with your insurance company to provide care. Out-of-network providers do not have a contract with your insurance company, so your cost to use them may be higher.
• Possible out-of-pocket costs

The documents you should receive from your insurance plan include:

• Summary plan description (SPD): an overview of what the plan provides and how it works
• Evidence of coverage (EOC): a detailed list of the plan’s health benefits and their costs
• Summary of benefits and coverage (SBC): a snapshot of the plan’s costs, benefits, and covered services

These documents will explain in detail what your plan covers. Insurance companies and employers (if your health plan is through your job) must give you a summary of your insurance coverage. Request a copy if you do not have it.

What to ask your care team

Before talking with the insurance company, ask your child’s care team for details about your child’s treatment plan. Having a clear understanding of your child’s treatment plan will minimize unexpected costs and help you make more informed decisions.

• Ask questions early: Ask questions from the beginning to get a better picture of what to expect and possible costs.
• Talk with your care team: Confirm the treatment plan with your child’s care team. Regular check-ins with the care team will reduce the chance of unexpected costs.
• Write everything down: Having written records will help when you review health care costs.

At the time of diagnosis

When your child is diagnosed with an illness, you will need to understand their diagnosis.

Ask your care team:

• What type of illness does my child have?
• What tests and procedures does my child need?
• Where will these tests and procedures take place?
• Which providers will perform these tests and procedures?

During treatment

The insurance company may ask questions about your child’s treatment plan.

Ask your care team:

• What is the treatment plan and time frame?
• When will these treatments occur?
• Where will they occur?
• Which providers will perform them?
• Will there be a need for home health care once treatment is over?

Prescription medicines

The insurance company may ask questions about the medicines prescribed.

Ask your care team:

• Which medicines are in the treatment plan?
• What medicines will manage side effects?
• Will my child need pain medicine?
• How often will my child get these medicines and for how long?
• Are there generic versions of brand-name medicines within the same drug class?

Home health care

During treatment, your child may need home health care from a parent or a specialized caregiver. Insurance plans may cover some of these costs.

Ask your care team:

• What kind of care will my child need after leaving the hospital?
• Will my child require a specialized caregiver?
• What kind of equipment will I need to care for my child at home?
• How long will my child require specialized home health care?

What to ask your insurance company

Once a treatment plan is in place, contact your insurance company to learn about the services covered and their costs. Ask them to assign an individual case manager or patient advocate to help answer questions.

The case manager can guide you through the insurance plan rules, coverage limitations, and out-of-pocket costs. Questions to ask the insurance company include:

• Where and from whom can my child receive care?
  • Most insurance companies have full lists of in-network providers online. Confirm whether your hospital is in network.
  • Sometimes a hospital is in network but a surgeon or specialist who provides care in the facility is not. Confirm each provider.
• Is a referral required from our primary care provider?
  • Some insurance plans require that a primary care physician provide a referral before you get care from specialists. 
  • Other plans may require approval from the insurance company for certain types of care.
• Is pre-approval from the insurance company required before seeing specific providers?
  • Some insurance plans require approval before you see certain providers. Check with your insurance plan to see if you should get an approval before starting care.
  • The insurance company may bill more for the care if you did not get the correct approvals. In some cases, the insurance company may not cover any of the costs.
• Are my child’s tests covered?
  • Your insurance plan may cover all tests and procedures required by your care team. Sometimes, tests will need to be at a specific hospital or care center to be covered.
  • The care team will likely not know which hospitals a specific plan covers. Confirm these details with the insurance company before getting care.
• Are prescribed medicines covered?
  • New medicines are coming out at a quick pace. The insurance plan may or may not cover them.
• Do we need to provide formal documentation?
  • The insurance company may ask for reports or forms that you must provide.

What to do if coverage is denied

The insurance company may question the medical necessity of some services, including:

• Stem cell (bone marrow) transplant
• Magnetic resonance imaging (MRI)
• Artificial limbs
• Biopsy
• Certain medicines

If the insurance company denies coverage, consider these steps:

• Discuss alternatives: Ask the care team if there is another option that the insurance plan does cover.
• Appeal the decision: You have a right to an independent medical review (appeal) if the insurance company denies your claim. Request a review by the insurance company to change its decision and provide coverage. This may require an appeal letter or form, along with more medical details. Staff members in your insurance company can guide you through the required steps of the appeal and review process.
• Ask about charity care: Ask the hospital, provider, or drug company if other programs may provide care at a reduced or no cost.

Other questions to ask your care team

• What tests, procedures, and treatments will my child need?
• Where and when will tests, procedures, and treatments take place?
• Who will perform these tests, procedures, and treatments?
• What alternatives are there for these tests, procedures, or treatments?
• Can my child take generic versions of brand-name medicines?
• How can I get coverage for a procedure if my insurance denies coverage?
• What kind of care will my child need after we return home?
• How can I get help paying for medical care?