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Getting the Most Out of Your Health Insurance

by Kimberly Calder, MPS

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If you or a loved one is living with cancer, you know how important your health insurance is to your health and financial stability. Since virtually all health plans are shifting more of the costs onto their enrollees, it is wise to make sure you are getting the best value out of your health plan. Understanding the terminology and rules of your plan and maximizing your benefits and appeal rights are critical to optimizing your coverage. Ask yourself these questions.

How well do you understand your health plan?
Many people are understandably confused by the terminology of health insurance. Make sure you understand the terms and concepts written into your health plan manual or member handbook. Online glossaries are available at and Never hesitate to request clarification from your coverage provider. You may also want to clarify the different entities involved in the administration of your health plan, which could include a third party administrator, a pharmaceutical benefits manager, a case manager, and an external review agent.

How well do you understand your benefits?
Your plan manual will include a list of covered benefits. It may include a separate list of excluded benefits as well. Understand that these are general guidelines and that other restrictions may apply. For example, your plan may cover home care, but that doesn’t mean you won’t be limited to a certain number of visits or hours of home care, or to certain home care providers.

When verifying a specific benefit with your health plan, ask for details in writing and be prepared to involve the physician who prescribed the drug or service to support his or her prescription more formally with your health plan. Health plans routinely require prior approval of many of the tests, procedures, medications, and specialized services people with cancer need. Your healthcare team is accustomed to these requests and will advocate for your needs when their specific recommendation is critical.

Many people are understandably confused by the terminology of health insurance.

Author of Article photo

Kimberly Calder

Your prescription drug coverage can be limited by the plan’s formulary (the specific list of drugs the plan will cover), quantity limits, specific doses, and brands. If your drug benefits are tiered, the higher the tier of your drug, the more you will have to pay out of pocket. Try to get as much detail about these types of restrictions on your prescription drug benefits as possible, and work with your doctor to identify any less costly alternatives that are likely to work well for you.

Are you in the best health plan for your needs?
If you are lucky enough to be covered by an employer or union that offers a choice of plans, take advantage of your annual enrollment period to carefully compare your options. With the help of your healthcare team, do your best to anticipate the types and amount of health services you may need in the coming year. Then prepare yourself for hard choices between limited benefits in one area, such as a high deductible or annual cap on prescription drugs, in exchange for a lower premium or richer coverage for something else. Take your time to research all your options, which may include coordinating your primary source of health insurance with another source of coverage if one is available to you. Some out-of-pocket costs are inevitable, but using a flexible spending account, allowable tax deductions, and other good financial planning can minimize their impact.

Medicare beneficiaries have such a wide variety of choices to make about organizing their benefits that consulting with a Medicare expert is recommended. In addition to Medicare itself (1-800- MEDICARE,, several nonprofit groups are available for consultation at no cost. You may also want to check with your State Health Insurance Program (SHIP). In addition to assisting with making decisions about your basic Medicare benefits, good counselors can alert beneficiaries to cost-saving possibilities, as well as provide guidance with Medicare prescription drug plans and supplemental (Medigap) plans.

Would you know how to file an effective appeal if you needed to?
Everyone has the right to at least two levels of appeal, but many people assume they can’t win or they conduct them ineffectively. Before filing an appeal, check your plan manual first since there is no point in appealing a denial for something that is clearly excluded from your coverage. Effective appeals are short, business-like letters that include your doctor’s best argument (including citations from relevant studies) for the medical necessity of a prescribed treatment. Finally, follow up and be polite.

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Kimberly Calder is the director of Insurance Initiatives for the National Multiple Sclerosis Society.

This article was published in Coping® with Cancer magazine, May/June 2009.