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Insurance Coverage and the Lessons We’ve Learned

What do you mean it’s Not Covered? 

As we prepared for Catherine’s first surgery, we were diligent with our insurance coverage and contacted our health plan to ensure the hospital, heart surgeon, cardiologist and medications were all covered. Imagine our surprise when we found out that the pediatric intensive care unit for the very hospital where she received her surgery was not covered by our insurance. We assumed that the hospital’s coverage carried over to all aspects of her care. This experience forced us to take extra measures to manage the cost of her care.

Annual cost adjustments occur for health plans and it is important to get the most out of your medical, dental and prescription plans. Here are some lessons we’ve learned:

1. Stay current on changes to your insurance coverage.

We realized that the coverage of drugs is not guaranteed from year to year for prescription plans. This means a drug covered in one year may not be on the list the following year. Drugs that are new to the market may be covered at some point. It is important to constantly check your coverage to properly manage the cost.

One of Catherine’s medications was experimental and not covered by insurance for several months and this set us back almost $300.00 per month. The following year it was approved for coverage with our prescription plan and our portion dropped by more than ninety percent.

2. Make sure your medical provider and pharmacy has your most recent insurance information.

At the beginning of the year, providers must verify your coverage. This can occur with almost any treatment and we have experienced this with therapy, prescriptions and immunizations. The pharmacy or medical provider has to contact the health plan to verify any changes in coverage. If you proceed with treatment or prescriptions without verification and coverage changes, this could result in an unexpected out of pocket expense.

Catherine receives speech and occupational therapy each week. There were times we had to place her treatment on hold until coverage was verified. If we proceeded with therapy, we signed a waiver to ensure we would cover cost of treatment if our insurance provider denied coverage. This could have cost us upwards of a few hundred dollars a week.

3. Try to stay in-network for your insurance plans

If your health plan is in network with a provider, you will typically pay less for services. If not, the entire expense could come out of pocket. The medical provider or facility will check the network status, but is also important for you to also check with your health plan.

A few weeks ago I needed dental work that required a visit to a highly recommended specialist. The specialist was out-of- network for my dental plan but her associate was in-network. The front office provided an estimate of services for in-network and out-of-network services. There was a significant difference in the cost and I opted for the associate because her reviews were strong and she was also in network. I also called my dental plan to understand my coverage.

We all want the very best health care for our loved ones and the wave of providers, copayments, and overall cost of care is cumbersome. Take an extra few minutes to ask crucial questions and follow up on coverage. This could possibly avoid any surprises with the cost of care.


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