Navigating the world of insurance can be complex. 

Navigating the complicated intricacies of the American healthcare system can make anyone want to pull out their hair.  Who should you contact for answers?  Should you call your insurance company first?  Should you contact your provider’s office instead?  Can you trust the information that you receive?  How can you avoid surprise costs and bills?  Why does it seem like you can never get a straightforward response?  In this series, we hope to address the most common (and yet, sometimes most complicated) questions that we have heard as genetic counselors regarding insurance coverage and the cost of genetic testing.  Unfortunately, due to the vast quantity of health plans currently available, we are unable to provide a full, comprehensive answer for every patient.  Rather, this will serve as a guide for the average patient as they attempt to traverse this difficult terrain.

We felt it most appropriate to begin with the absolute basics of insurance coverage.  Many people have great difficulty comprehending their insurance coverage simply because no one has bothered to take the time to define the general terms; even those of us who work within the healthcare system periodically struggle while negotiating the tangled web of insurance.

Firstly, as patients, it is vital that you participate in the investigation of your coverage and that you make the best effort to understand the general benefits of your insurance policy.  As providers, we do not expect you to know and understand every minute detail of your policy, but a broad understanding is important.  To begin this process, prior to a medical appointment, you can go onto your insurance provider’s patient portal or call the Member/Customer Service phone number on the back of your insurance card.  The most important initial questions are largely focused on your deductible, your coinsurance, your copays, and non-covered benefits.  This first entry will focus solely on defining these fundamental terms.  If you already have a firm grasp on these terms, please tune in to the next blog in this series for more in-depth information regarding genetic testing!

It's important to understand your healthcare coverage by checking in with your insurance company.

A deductible is an amount of money for which a person is responsible to pay prior to their insurance covering certain (or any) services.  For some insurances, the deductible applies to all services, such as laboratory studies, prescription medications, ultrasounds, consultations, X-rays, office visits, urgent care visits, and emergency room visits.  For other insurances, the deductible only applies to certain services, such as surgeries.  Generally, if you have dependents (such as your spouse or children) on your plan with you, each person will have an individual deductible and there will also be a family deductible.  When individuals pay for their health care services, their payment goes toward their individual deductible, and it is credited toward the family deductible.  Once the family deductible is met, all individual deductibles are considered to be complete as well.  When you call your insurance provider regarding your deductible, here are a few critical questions to ask:

  1. Does my insurance plan have a deductible?
  2. To what services does my deductible apply?
  3. How much is my individual deductible?  How much is my family deductible (if you have dependents on your insurance plan as well as yourself)?
  4. What is my deductible for in-network versus out-of-network providers and services?
  5. How much of my individual deductible have I met (and/or your dependent’s individual deductibles)?
  6. How much of our family deductible have we met?
  7. What is my out-of-pocket maximum?

Coinsurance is a set percentage of medical costs for which a person is responsible for paying, often after a deductible is met.  Therefore, for services covered by coinsurance, actual costs for various services can differ substantially.  For example, commonly, insurances will pay 80% of a specific medical cost, and you are responsible for the remaining 20% (you have a “20% coinsurance” plan).  However, your out-of-pocket cost varies as the services billed to your insurance also range in cost.  For instance, if a $100 charge is billed to your insurance, you will be responsible for $20 (20% of $100).  On the other hand, if a $1,000 charge is billed to your insurance, you will be responsible for $200 (20% of $1,000).  When you call your insurance provider regarding your coinsurance, here are a few essential questions to ask:

  1. Does my insurance plan have coinsurance(s)?
  2. To what services does my coinsurance apply?
  3. How much is my coinsurance for in-network versus out-of-network providers and services?

A copay is a set price paid for a particular service, often after a deductible is met.  For most services, you will have either coinsurance or a copay, not both.  Therefore, if you have a copay, you should pay the same amount for the service completed, regardless of the cost billed to your insurance.  For example, if you have a $50 copay for urgent care visits, you will pay $50 when you visit an urgent care facility, regardless of the total bill to your insurance.  When you call your insurance provider regarding your copay, here are a few noteworthy questions to ask:

  1. Does my insurance plan have copay(s)?
  2. For what services do I have a copay?
  3. How much are my copays for in-network versus out-of-network providers and services?

As the name implies, non-covered benefits are medical services for which an insurance provider offers no coverage or payment whatsoever.  What is considered a non-covered service can vary significantly between plans.  Typically, you are responsible for the entire cost of a service that is a non-covered benefit.  A non-covered benefit differs from a denied service.  A denied service is usually a covered service; however, you did not meet your insurance’s qualifications or specific criteria for coverage of the service in question.  For example, insurance providers may offer coverage for specific services for “high risk” individuals only.  The insurance company dictates what “high risk” criteria you must meet to qualify for coverage of this particular service.  If you do not have a “high risk” indication as determined by your insurance company, you may be denied coverage for the performed service.  For denied services, you or your provider may be able to submit an appeal to try to reverse your insurance’s decision not to pay toward your medical care.  On the other hand, a non-covered benefit is, as noted previously, simply not covered regardless of the circumstances.

Lastly, we must address in-network versus out-of-network coverage.  For most insurances, certain service providers participate with that insurance plan; therefore, an insurance provider has deemed them “in-network.”  Other service providers do not participate or have not agreed to the costs set forth by the insurance plan.  These service providers are deemed to be “out-of-network.”  You should inquire with your insurance provider how to verify which service providers are in-network and which are out-of-network.  Sadly, differentiating between these two statuses is one of the most likely reasons individuals are surprised by high, unexpected health care expenses, even individuals attempt to do as much research into their plan as possible.  For example, you may thoroughly research the hospital that is closest to you.  To your knowledge, all departments and physicians are in-network.  However, at any given time, an out-of-network doctor may be covering for an in-network doctor.  In this scenario, you would pay the out-of-network price for being treated by that doctor, even though the hospital (the facility) is in-netwrok.  This has been reported across the country routinely, most commonly in emergency care.

Now that we have tackled some insurance basics, for our next installment, we’ll apply what we’ve learned to the complicated topic of genetic testing.  Check back periodically for the next installment in this insurance series.