Plain-language explainers on deductibles, networks, prior authorization, EOBs, cost estimates, appeals and clinical trial coverage, each sourced.
Deductibles, coinsurance and the out-of-pocket maximum
The three numbers that decide most of what you pay in a year.
The deductible is what you pay for covered care each plan year before the plan starts paying its share. Some services, like preventive care or copay-based visits, may be covered before you meet it.
After the deductible, coinsurance is your percentage of each covered bill (for example 20%), and the plan pays the rest. A copay is a fixed amount for a visit or prescription instead.
The out-of-pocket maximum caps what you pay for covered, in-network care in a plan year. After you reach it, the plan pays 100% of covered in-network services. Premiums and out-of-network care usually do not count toward it.
Worked example
Illustration only, with made-up numbers: with a $2,000 deductible (none met yet), 20% coinsurance and a $6,000 out-of-pocket maximum, a $10,000 covered bill would cost $2,000 (deductible) + 20% of the remaining $8,000 ($1,600) = $3,600. A second bill like it would be capped at the $2,400 left before the maximum.
Questions to ask
How much of my deductible and out-of-pocket maximum have I met this year?
Do chemotherapy drugs, infusions or radiation fall under my medical or pharmacy benefit?
A hospital being in network does not mean every doctor there is.
A network is the group of doctors, hospitals and suppliers your plan contracts with. Out-of-network care usually costs more, and HMO and EPO plans may not cover it at all except in emergencies.
Check three things separately: the doctor, the facility, and the specific location. Surgeons, anesthesiologists, radiologists and pathologists may each bill separately.
The most reliable answer comes from calling the member services number on your insurance card and asking for a reference number for the call. Online directories can be out of date.
Questions to ask
Is Dr. [name], NPI [number], in network for my plan at [this location]?
Is the hospital or infusion center itself in network?
Will the anesthesiologist, pathologist and radiologist be in network? If not, am I protected by the No Surprises Act?
Some treatments need the plan's approval before you get them.
Prior authorization (also called preauthorization or precertification) is a decision by your plan that a service, treatment or drug is medically necessary before you receive it. Imaging, surgery, radiation, infusions and specialty drugs often need it.
Your doctor's office usually files the request, but you can ask whether it has been submitted and approved. Without it, the plan may refuse to pay even for a covered service.
Approval is not a promise of payment: the plan can still review the claim afterwards.
Questions to ask
Does this treatment need prior authorization, and has it been approved?
Who at your office is handling it, and how long does approval usually take?
If it is denied, will you request a peer-to-peer review or help me appeal?
An EOB is not a bill. It shows what the plan did with a claim.
After a claim is processed, your plan sends an Explanation of Benefits. It lists the service, what the provider charged, the plan's allowed amount, what the plan paid, and what you may owe.
Compare the EOB with the bill from the hospital or doctor before paying. The amount you owe on the bill should match the 'patient responsibility' on the EOB.
Look for denied lines and their reason codes. A denial for missing prior authorization or a coding error can often be fixed by the provider's billing office.
Questions to ask
Why was this line denied, and what would change the decision?
Has the provider been paid the allowed amount, and why does my bill differ from the EOB?
How to request a cost estimate (and the good faith estimate)
Ask the plan and the provider. Uninsured and self-pay patients have a legal right to one.
If you have insurance, ask your plan for an estimate of your share using the procedure name or billing codes from your care team, and ask the hospital's financial counselor for their estimate.
Under the No Surprises Act, if you are uninsured or not using insurance, providers must give you a good faith estimate of expected charges for scheduled care. You need that estimate to dispute a final bill that comes in substantially higher; CMS explains the dispute process and how to complain if you never got one.
NuDavid's cost calculator applies your own deductible and coinsurance to an amount you enter. It is an arithmetic aid, not a quote.
Questions to ask
What billing codes will be used for this treatment?
Does this estimate include the facility, the doctors, the drugs and anesthesia?
You have the right to an internal appeal and, usually, an independent external review.
If your plan denies a claim or a prior authorization, it must tell you why and how to appeal. The denial notice tells you the deadline, so keep it and note the date.
If the internal appeal is denied, you can usually request an external review by an independent organization, whose decision the plan must follow.
If your care is urgent, ask for an expedited (urgent) appeal. Your doctor can support the appeal with a letter of medical necessity.
Questions to ask
What exactly was denied, and under which plan rule?
What is the deadline for my appeal, and can it be expedited?
Will my doctor write a letter of medical necessity?
Routine care in a trial is usually covered. The study drug and research-only tests are usually paid by the sponsor.
Federal law (Public Health Service Act section 2709, added by the Affordable Care Act) says most non-grandfathered private plans cannot deny you participation in an approved cancer clinical trial, and cannot deny coverage of routine patient costs: the care they would cover if you were not in a trial.
Routine costs do not include the investigational drug or device itself, or tests done only to collect research data. Those are often paid by the trial's sponsor. Plans do not have to cover out-of-network trial sites unless your plan already has out-of-network benefits.
Medicare covers some costs in qualifying clinical research studies, such as office visits and tests; after the Part B deductible you may pay 20%. The NCI notes that Medicaid covers routine patient care costs in clinical trials, with eligibility set by each state.
Ask the study team whether the trial offers help with travel, lodging or other non-medical costs.
Questions to ask
Which costs does the study sponsor pay, and which will be billed to my insurance?
Is this trial site in my plan's network?
Does the study reimburse travel, parking or lodging?
