Navigating the Ins and Outs of Insurance Coverage

by Erin Bradshaw, Patient Advocate Foundation

Selecting a health insurance plan is an important decision and requires careful consideration. It may feel complicated and overwhelming. But by investing some time in comparing your options, you can choose the best plan for your treatment needs and any other special considerations that matter to you.

Types of insurance

Insurance is typically obtained through an employer or a spouse’s employer; employees may enroll when they first join the company, during open enrollment periods, or after a qualifying life event.

Insurance can also be purchased through state or federal health exchanges, which were created through the Affordable Care Act. Anyone can enroll in these plans during the designated open enrollment periods, and you may be eligible for subsidies based on your income level.

Medicaid provides health coverage for low-income people; some states have expanded their income guidelines for eligibility. There are specific programs for Medicare eligible as well. You can see if you qualify and apply at, or contact your local social services agency.

If you are Medicare eligible and low income, you may be eligible for Low-Income Subsidy (also called Extra Help) under the Part D prescription drug program. To learn more and apply, visit

Programs vary depending on state and age or disability. The National Council on Aging provides a BenefitsCheckUp service ( that can help narrow down eligible programs. Finally, Medicare coverage is available to those over 65 as well as to qualifying people with disabilities, or those who receive Social Security Disability Insurance.

Choosing the right plan

The right insurance for you will depend on your unique needs and health situation. For example, you may have a preferred pharmacy, want to seek specialty care without a referral, or wish to travel and seek a more expanded network of providers. Look at the amount and type of treatment you have received in the past. Though it is impossible to know every future medical need, this can help draw attention to trends to help make you make an informed decision.

Here are a few tips for selecting insurance:

  1. Determine when open enrollment is for you and be certain to review all options and make any changes to your old plan or sign up for a new plan within the allotted time frame.
  2. Do not just assume the plan you have currently will maintain the same benefits and cost structure; they may change from year to year.
  3. Review the network of approved providers, hospitals, and facilities. Out-of-network care will cost you more, or worse, offer zero coverage and make you liable for the full cost of service. If you prefer the most open network and would rather choose your own specialist, a PPO would likely be best over HMO plans, for instance.
  4. Compare all benefits offered as well as any exclusions or limitations. Verify that your current treatments and medications are covered. See if there are any limits on services as well as what tiers your medications fall under.
  5. Compare estimated annual cost. Premiums are not the only financial consideration— the best plan may not be the cheapest premium. Know the maximum financial impact by reviewing all out-of-pocket costs, including the annual deductible, copays, and coinsurance responsibilities. Pay special attention to the maximum out-of-pocket responsibility; once you meet that cap, your health plan will pay 100 percent of all covered care costs for the rest of the year.

Other cost-savings strategies

Ever after you have picked a plan, there are other strategies for saving on treatment.

Flexible spending accounts or health savings accounts
Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) are great ways to save on eligible health care costs, like deductibles, coinsurance, copayments, and other out-of-pocket costs. Both involve setting aside funding specifically for health care expenses and offer tax savings, but the amounts and eligibility requirements vary. For example, FSAs are only offered through employers, while HSAs are available only to individuals with a high-deductible insurance plan.

Drug coupon saving programs
Ask your prescribing doctor or pharmacist about manufacturer coupons; a website for finding available coupons by drug name is

Free drug programs
Many manufacturers offer patient assistance programs that offer free drugs to qualified patients without prescription insurance coverage. Medicine Assistance Tool ( will list all known programs and guidelines by entering the name of the drug.

Copay assistance programs
Charitable copay programs offer direct financial support to insured patients. These programs require you to complete an application to determine if you medically and financially qualify based on individual program requirements. If approved, these programs can help with your out-of-pocket cost related to medical expenses. To find out if there are available programs search by your diagnosis at or

Drug discount savings programs
Compare prescribed medication in tools available on your insurers website to explore cost against possible generics and mail-order for more affordable options. It may be cheaper to self-pay at a discounted price vs. using health insurance benefits through websites such as

Dealing with insurance denials
Even after selecting the best plan, you may find yourself facing denials of coverage. Insurance denials can stem from a variety of different causes. But you have the right to appeal these decisions and it is strongly encouraged that you exercise this right. Be certain you follow the timelines outlined in the denial letter and stay factual when drafting an appeal. Your doctor’s office can be your biggest advocate; seek out their help in this process with letters of support along with any clinical evidence to contest the denial.

The Patient Advocate Foundation can also help at no cost! Contact us for help at 800-532-5274 or navigate our online education resources at