Understanding your health insurance

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 can help you plan for out-of-pocket (OOP) expenses. It can also help you get the most coverage possible for the tests and treatments 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.

On this page, you’ll find terms to help you understand how your insurance plan works. We offer things to think about, like how to organize your paperwork, and to be aware of, like what your plan does and does not cover, as you begin this process.

Health insurance words to know

Appeal. If your health insurance company does not pay for a healthcare provider or service, you have the right to appeal the refusal to pay. Your appeal will be reviewed by a third party.

Assignment. A process in which your medical provider bills Medicare directly for their portion of the cost of your care, and requires you to pay only your coinsurance or deductible. This is called “accepting assignment.”

Benefits. The healthcare items or services covered by a health insurance plan.

Coinsurance. A percentage of the bill for a healthcare service that you must pay after you’ve paid your deductible.

Copayments (or copays). A set amount you pay for each medical service you get, such as a test or doctor visit, after you’ve paid your deductible.

Cost-sharing reduction. A discount that lowers how much you pay for coinsurance, copays, or deductibles.

Deductible. Amount of money you pay out of pocket for healthcare services before your insurance plan starts to pay.

Disability Insurance. An insurance plan that pays some of a person’s income if they cannot work due to disability from an illness or if they get hurt.

Explanation of Benefits (EOB). Shows the total charges for a doctor visit. It lets you know what your insurance plan covers and what you’ll pay when you get a bill from your doctor. An EOB is not a bill.

Fee-for-Service (FFS) Plan. With an FFS plan, providers are paid for each service (including tests and office visits) provided.

Flexible Spending Account (FSA). A program through your employer that lets you pay for many out-of-pocket costs tax-free.

Group health plan. Insurance plan provided by an employer or employee organization that offers healthcare coverage to employees and their families.

Guaranteed issue. Requires health insurance plans to allow you to become a member regardless of health, age, or gender.

Health Insurance Marketplace. Sometimes called “the exchange.” A service offered by the federal government that helps people shop for and enroll in health insurance. People can enroll in a Marketplace plan November 1 to January 15 each year. Be sure to check the start date for coverage, especially if you need your coverage to start January 1. Some states run their own Marketplaces, and they may have longer enrollment periods.

Health Maintenance Organization (HMO). A type of health insurance plan that limits coverage to care from doctors who have a relationship with the HMO. An HMO usually doesn’t cover out-of-network care.

Health Savings Account (HSA). A type of account that lets you set aside money (pre-tax) to pay for some medical expenses.

Hospice. Care that focuses on treating side effects and providing care and quality-of-life support as people near the end of life.

Individual insurance policy. A plan for people who don’t have job-based health coverage (regulated by state law).

In network. When healthcare providers are on your insurance plan’s list of approved providers and their services are covered by your plan. Also called network or preferred providers. Even if you see an in-network provider, you still may have costs (copays, for example) to pay.

Maximum out-of-pocket limit. The most money you must pay for healthcare costs in a year before your policy pays 100 percent of the allowed amount for the rest of the year.

Medicaid. A state-run insurance program that gives free or low-cost health coverage to some low-income people, families and children, pregnant people, older people, and people with disabilities.

Medicare. Federal health insurance program for people 65 and older and some younger people with disabilities.

Open enrollment period. A time, usually once a year, when you are allowed to enroll in health insurance coverage. Open enrollment is available for employer plans, the Health Insurance Marketplace, and Medicare.

Out of network. Healthcare providers who are not on your insurance plan’s list of approved providers. You may have to pay a higher copayment or coinsurance to an out-of-network provider.

Out-of-pocket expenses. Expenses you must pay when a treatment or service is not covered by insurance or covered only in part. Includes deductibles, coinsurance, and copayments for covered services.

Point-of-Service (POS) Plan. A type of health insurance plan with which you pay less for using in-network providers. Your PCP will be required to give you a referral to see other doctors in the network.

Preauthorization. Approval from your health plan or insurer saying that your treatment or service is medically necessary. You may need preauthorization before your insurance will pay their part of your treatment costs. But while some treatments require preauthorization, getting approval does not mean the plan has to cover them.

Preexisting condition. A medical condition or problem (including cancer) a person had before joining a health insurance plan. Most insurance companies cannot refuse to cover treatment for preexisting conditions.

Preferred providers. In-network doctors and other providers who work with your health insurance plan.

Preferred Provider Organization (PPO). A type of health insurance plan with which you pay less if you use the supplied list of preferred providers. Generally, you do not need a referral to see a specialist. You can used providers outside of the network, but you will pay an additional cost.

Premium. The fee you pay to your insurance company every month.

Primary care provider. A doctor, nurse, or other provider who supervises your overall healthcare needs.

Referral. A written order from a doctor to consult with another type of doctor, usually a specialist.

Special enrollment period. A time outside the open enrollment period when you can sign up for health insurance. You qualify for this period if you lose your health coverage or your household income drops below a certain amount, or if you move, get married, have a baby, or adopt a child.

Organize papers, bills, and records

As someone diagnosed with breast cancer, you may get a lot of bills and paperwork in the mail, by email, and directly from your doctors. Create a file and organize the papers as soon as you get them. Keeping an organized file of all the papers your insurance company sends you, and any paperwork that your insurance company may request, can make things easier.

The earlier you start a file, the more information you will be able to give if your insurance provider asks for a receipt or verification. Include these in your file:

• Paperwork from diagnostic tests, treatments, follow-up care, and insurance claims
• A list of appointment dates and any payments made
• Notes taken during doctor appointments
• Your insurance information, bills, and receipts
• Test results
• A list of resources or websites you find useful
• Names of any insurance or hospital representatives you speak with by phone or email, along with the date of the correspondence and any notes you take

Ask for professional help to navigate insurance and treatment decisions

Once you’ve met with your healthcare team and have begun to make treatment planning decisions, resources are available to you if you have concerns about costs.

You can find professional help in these places:

• Your health insurance provider has case managers who can help you get the most out of your insurance.
• Your healthcare team may include a patient navigator, financial navigator or advocate, or oncology social worker. These team members are there to support you and facilitate communication between your doctors and health 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 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

Health 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 certain 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, such as acupuncture.
• Any OOP expenses, like copayments or deductibles. Some providers may require these payments from you, while others may not.
• Any coinsurance requirements. Coinsurance is like a copay 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 copay and a coinsurance amount for certain care.

Making a list of costs can help you to budget for your medical expenses and stay in control of your finances. Many insurance providers and employers offer broad health insurance plans that may cover more than your current plan for a higher monthly membership fee (a premium). If you find that your expenses are high with your current plan, consider switching to another plan during an enrollment period.

Explore limitations and requirements

Health insurance plans differ based on what employers choose to offer or what you choose if you are purchasing a plan on your own. Plans also differ on what they do and do 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 doctor for a referral before you are able to see a specialist.
• Specialist coverage. Sometimes a healthcare plan will cover certain services from one medical specialist and not another. Find out which specialists participate in your plan.
• Mental health care. Most insurance plans cover some mental health counseling services. Coverage is often limited to a certain number of counseling sessions.
• In-network vs. out-of-network providers. Many insurance plans require holders to see doctors in their “network” to pay the lowest possible fees. If you see an out-of-network provider, you will likely have to pay a higher copay or the whole cost of treatment. HMO, PPO, and POS plans may all accept 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 get approval for treatments or tests in advance so they can decide if these treatment or tests are medically necessary. Someone at your doctor’s office usually handles getting pre-authorization for you. The process can take a few hours to a few days.
• Prescriptions. Find out if they are covered, and if you need to get name-brand or generic medicines for insurance to cover costs.
• Hospice care. Most employer-based and private insurance providers offer some coverage for hospice care. Medicare Part A offers hospice benefits for people who are eligible. Some states offer hospice benefits with Medicaid. You may want to find out what your plan covers and what criteria need to be met for you to be covered.

No Surprises Act

The No Surprises Act tries to limit what you pay out of pocket for medical services, whether you have health insurance or not. A surprise medical bill is an unexpected bill. People can receive surprise bills from a healthcare provider or center for services they did not know at first were from an out-of-network provider or center. A surprise bill can also result from emergency services.

Women’s Health and Cancer Rights Act

The Women’s Health and Cancer Rights Act (WHCRA) helps protect women who choose to have breast reconstruction surgery after a mastectomy. The law requires most group insurance plans, health insurance companies, and HMOs that cover mastectomies to also cover breast reconstruction.