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If you are changing healthcare providers and/or healthcare coverage plans, you need to learn (“NOW” not later) the details of how those changes will influence the choice of your doctor and medication coverage.  Contact your insurance representative and/or your Benefits Department by calling the number on the back of your insurance card.

Questions to Ask


  • Is your medical center (the place where your doctor practices) in network or out of network?
  • Is there an individual and/or family deductible?
  • Do I have a co-insurance?  If so, what is the amount?
  • Does my deductible count toward my out-of-pocket maximum?
  • What is my overall individual/family out-of- pocket maximum?
  • Do I need to have any visits, tests, or other services pre-certified or prior authorized prior to the service be done?

Inpatient Benefits

  • Do I have a yearly or life-time max on inpatient visits?
  • Are there any additional costs associated with an inpatient stay?

Outpatient Benefits

  • Are there any additional charges for outpatient visits?
  • What is my physician copayment for primary care physician and or specialist?
  • Is there a facility charge associated with the hospital?
  • How many occupational therapy, physical therapy, and speech therapy visit do we get per person each year?

Prescription Benefits

  • What are my prescription benefits for brand name and generic drugs?
  • Are there any prescription limitations?
  • What is my out-of-pocket maximum on prescription drugs?
  • If I am already on a brand-name drug (because I tried other generic drugs and they did not successfully treat my condition) will I be forced to re-try generics on the new formulary prior to being reimbursed for my current drug?
  • Have a list from your doctor of potential prescriptions and ask if these drugs are covered under your plan.

Emergency Room/Urgent Care

  • What is my out-of-pocket cost for visiting the emergency room/urgent care center?
Insurance Terms to Know

Balance Billing – A billing practice in which you are billed for the difference between what your insurer pays and the fee the provider normally charges.

Coordination of Benefits (COB) – Provisions made to avoid duplication of payments if more than one policy holder in the family has medical insurance.  For purposes of filing claim forms, generally, one individual is determined to be the primary insured, or the insured adult with the earliest birthday in the year is the primary Insured over all others in the family.

Coinsurance – A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.

Copayment – A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received.

Deductible – A fixed dollar amount during the benefit period (usually a year) that an insured person pays before the insurer starts to make payments for covered medical services.  Plans may have bother per individual and family deductibles.

Exclusion – An exclusion is any condition, procedure or item that the insurance policy does not cover.   Group policies and individual policies typically have a list of condition, types of equipment and situations that are not covered for anyone insured.

Explanation of Benefits (EOB)– The statement sent to a participant in a health plan listing services, amounts paid by the plan and total amount billed to the patient.

Pre-Authorization – An insurance plan requirement in which you or your primary care physician must notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense.

Maximum Plan Dollar Limit – The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan.  Plans can have a yearly and/or lifetime maximum dollar limit.

Maximum Out-of-Pocket Expense – The maximum dollar amount a group member is required to pay out of pocket during a year.  Until this maximum is met, the plan and group member shares in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum.

Additional Issues of Concern

  • Medical devices may have a 2.5% excise tax attached. A VNS (Vagus Nerve Stimulation) and even crowns for teeth are considered a “medical device.”
  • Employees should contact and get the human resource/benefit person involved for “special circumstances.”

     Children under the age of 3 using Afinitor. Sometimes it requires that the claim be run under the “medical treatment” (using chemotherapy for brain tumor) rather than “pharmacy benefit.”  Many insurance companies will state that it’s a chemotherapy drug not an FDA approval for SEGA (subependymal giant cell astrocytomas) this requires a lot of explanation and referral to the correct arm of the insurance. This may take a lot of leg work and phone calls to even find out who the correct person you need to contact. 
  • A SEGA is not considered an emergent (urgent) condition by some state Medicaid boards.  You will need contact your State Medicaid Board to find out if this is true in your state.  If it is not considered an urgent condition you may not be able to travel out of your state for treatment.  This is an issue if there are no TSC Clinics in your state and you are being treated by a TS Clinic out of your state.
  • Some patient assistance programs for medications may not be helpful in patients under the age of 1 year.

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