Getting a call from your doctor saying that you have a newly diagnosed health condition that requires immediate treatment is a very scary feeling. You become fearful of the unknown and suddenly your world changes and takes you down a road where you need to determine the next steps. That’s why you need to ask your health insurance carrier some important questions after receiving your diagnosis.
A newly diagnosed health condition is stressful and causes great concern in and of itself, but it also brings additional concerns:
- The health concern- will I be okay?
- The money concern- how much is this treatment going to cost and can I afford it?
- The benefits concern- will my insurance carrier cover these medical expenses?
These are all valid concerns, but rest assured that your health insurance carrier wants to alleviate or ease your mind of some of these concerns so you can focus on your health and getting the treatment you need to get better.
Health insurance can be complex if you do not understand your medical benefits. It is important to educate yourself so you understand the difference in cost of care when either dealing with a preventive care visit or a newly diagnosed health concern, which turns into a diagnostic visit.
Health itself can get stressful and dealing with the insurance company is another added stress. These 3 questions to ask your health insurance carrier will help alleviate the stress of the unknown costs, ease your mind about the process, and help educate you so that you understand your benefits.
If you’ve been recently diagnosed with a health condition, these are the questions you need to ask when calling your health insurance company:
1. Health Concern- Now what?
Step 1- Pull out your medical insurance card or download your medical insurance card online through your health insurers member portal. There will be a member services number on your card to call.
Here are the questions to ask and how to word them:
- I was newly diagnosed with a health condition; will you please help me find the right in-network provider for my specific condition? (In-network means that your out-of-pocket cost will be lower than going to an out-of-network provider). Ask for a list of medical providers or at least ask for a minimum of three different providers to choose from.
Note: Your health insurance carrier should be able to search by geographical location and specialty via a provider finder search tool.
Depending on the health condition, you may need multiple doctors, hospitals, laboratory location options, and radiology locations. All these need to be in-network. In addition to asking for a list of the medical providers and labs listed above, it is also important to have the insurance carrier locate the nearest in-network hospital for you, in case of an emergency.
Remember, out-of-network means that they do not participate with your insurance, therefore, your out-of-pocket cost share will be significantly higher. You should also ask for an in-network laboratory for any blood or urine samples that may need to be taken. Some doctors or facilities just send out the lab work or send you to the nearest location without checking if the laboratory participates or is in-network with your health insurance carrier.
This is a big deal if not in-network. Your out-of-pocket costs will be astronomical, and as a result, you could possibly end up not being covered by the insurance. You need to ask for a list of all of the in-network providers you may need and try to avoid out-of-network providers, in order to minimize the stress already in the health concern itself.
2. Money Concern
Knowing how much you will have to pay for an out-of-pocket medical expense is crucial. Especially, if ongoing medical care is needed. Most medical insurance carriers have an estimated cost calculator. For example, if you need an MRI or CT scan, your health insurer should be able to locate the nearest in-network facilities and determine which facility would provide the lowest out-of-pocket cost share depending on your benefits.
As another example: “Facility A” down the street may charge $5,000; however, “Facility B”, which is a little further away may charge $4,000.
This is the question you should ask your health insurance in regards to cost-share:
- I need to get an MRI, can you please tell me which in-network facility would be more cost-effective between the three facilities closest to my home?
Note- If your health insurance carrier does not have a cost estimator tool to determine your cost share, you can call the facility directly and ask them to give you an out-of-pocket estimate for the scan and services rendered.
3. Benefits Concern
Money and Benefits go hand-in-hand. Understanding your health insurance benefits is important in order to determine any out-of-pocket expenses for medical care. Whether you are going for an annual check-up, flu shot, or extensive medical services, you need to know how your benefits will cover the cost of these services.
Preventive Services: Preventive services are considered preventive exams, screenings, physicals, and wellness visits. Most medical insurance companies cover these preventive service visits at 100% or there may be a small co-pay. However, if you are in the doctor’s office for your wellness exam and you start telling the doctor about your hurt knee or sinus infection, then the wellness exam turns into a diagnostic visit, which will be charged as an “office visit” resulting in a higher out-of-pocket expense.
Diagnostic Services: Diagnostic services are considered a medical condition that needs or has a diagnosis. The doctor is diagnosing a condition; therefore, they would charge for a diagnostic office visit, which would most likely result in a deductible.
These are the important questions to ask your medical insurance carrier when asking about benefits:
- What is my coverage for preventive exams?
- What is my in-network deductible?
- What is my coverage for diagnostic services?
- What is my emergency medical coverage?
- What is my coverage for x-ray/imaging services?
- What is my durable medical equipment coverage?
- Are hearing aids covered?
- Are wheelchairs covered?
- Are crutches covered?
- Is a CPAP “Continuous Positive Airway Pressure” covered?
- What is my maximum in-network out-of-pocket expense?
- Are my specific services covered under my plan?
Some insurance companies do not cover certain medical procedures or devices such as hearing aids, wheelchairs, etc. It’s important to ask the medical insurance carrier if your plan covers the medical procedure or medical devices you need.
Medical insurance carriers can also send you a benefits booklet that outlines all your benefits. You can request a copy or ask where you can download a plan specific benefit booklet. You will need this benefit booklet as a guide to understand the cost and benefit coverage for future minor medical procedures, international benefits, major medical procedures, and any durable medical equipment coverage.
Being educated will help you alleviate the stress of any surprise diagnosis or unforeseen medical expense. Print this out and keep it with your medical card, so you can be sure to ask the right questions when calling your health insurance carrier. Now that you know what to ask for, you can put the focus back on your health.