How to Figure Out What Health Insurance Covers

What does your health insurance plan cover?

Health insurance helps pay for doctor visits, tests, medicines, and hospital care. Every plan is different, so it is important to know what your plan will cover before your child begins treatment.

Review your insurance plan documents to understand:

• Benefits coverage: What services the plan will pay for
• Provider networks: Which doctors and hospitals are considered to be in network for your plan. Your insurance company has an agreement with the in-network providers. You usually pay less to see them. Out-of-network providers do not have a contract with your insurance company, so you may pay more for care.
• Possible out-of-pocket costs: What you may have to pay yourself

For a general introduction to insurance basics, visit Understanding Health Insurance. 

Start with your plan documents

Your insurance company or employer should give you written information about what your plan covers. These documents may include:

• Summary plan description (SPD):  An overview of what the plan provides and how it works
• Evidence of coverage (EOC):  A detailed list of benefits and costs
• Summary of benefits and coverage (SBC):  A summary of the covered services and common costs

If you do not have these documents, request copies. They may also be available through an online patient portal.

What to ask your care team

Before talking with the insurance company, talk with your child’s care team. They can help you understand what care your child will need so that you can ask the insurance company the right questions.

Write notes or use a notebook. This will help you stay organized as treatment continues.

At the time of diagnosis

Ask your care team:

• What illness does my child have?
• What tests and procedures are needed?
• Where will these tests and procedures take place?
• Which providers will be involved?

During treatment

Your insurance company may ask for details about your child’s treatment plan.

Ask your care team:

• What is the treatment plan and timeline?
• When will these treatments happen?
• Where will they take place?
• Who will provide the care?
• Will my child need home health care during or after treatment?

Prescription medicines

Ask your care team:

• Which medicines are in the treatment plan?
• Will my child need medicines for side effects or pain?
• How long will they need these medicines?
• Are there safe generic options for these medicines? 

Home health care

Some children need care at home while recovering. Insurance plans may cover some of these costs.

Ask your care team:

• What care will my child need at home?
• Will my child need a nurse or special caregiver?
• What equipment will we need?
• How long will this care be needed?

What to ask your insurance company

Once a treatment plan is in place, contact your insurance company. Ask if your child can be assigned a case manager or patient advocate. This person can help guide you through the process, explain coverage rules, and answer questions.

Questions to ask your insurance plan

• Where can my child receive care and who can give it?
  • Confirm if the hospital, doctors, and specialists are in network.
  • Ask if any providers involved in the treatment are out of network. 
• Are referrals or pre-approvals required?
  • Some plans require a referral from your child’s primary care provider. 
  • Some services need approval from the insurance company before care is given
  • Ask what happens if approval is not obtained. Some plans will not pay for care without it.
• Are my child’s tests and procedures covered?
  • Confirm that the tests that your care team recommends are covered.
  • Some plans require certain tests to be done at specific centers or facilities.
  • 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?
  • Ask if the medicines on the treatment plan are covered.
• Do we need to provide documentation?
  • The insurance company may ask for medical records or forms.
  • Ask where to send documents and how long decisions usually take.

What to do if coverage is denied

Sometimes insurance companies deny coverage because they need more information or do not think a service is medically necessary. 

Common services that may need review include:

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

If the insurance company denies coverage, consider these steps:

1. Talk with the care team: Ask if there are alternative tests or treatments that your plan may cover.

• A letter or form
• Medical records
• A statement from your child’s provider

The insurance company can explain each step.

2. File an appeal: You have the right to ask the insurance company to review its decision. An appeal may require:

3. Ask about financial help: Hospitals, clinics, and some drug companies offer programs that may help with costs.

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