Health Insurance 101

Figuring out exactly how insurance plays into your testing decision can seem tricky, but understanding some of the basics gives you a definite edge. Learning just a few common insurance terms leads to better conversations with your insurer and your healthcare provider.

While you may not need go over every page of your policy or coverage booklet, you’ll want to understand a handful of common ideas and terms – we cover them here – you’re likely to hear as you talk with your insurer about genetic testing.

Some helpful tips:

  • Listen carefully – and even take notes – as you work with your insurer.
  • Make sure you’re absolutely clear on the types of costs you may incur. Ask as many follow-up questions as you need.
  • Take advantage of expert help. Your healthcare provider’s office or your genetic testing lab may have staff that deals with the ins and outs of insurance every day. Genetic counselors also have good knowledge of how your insurance will work.

Validating Coverage

How do I pre-verify my health insurance coverage?

Start by collecting some key information about your test to help your insurer estimate your portion of the costs. Before you call member services for your policy (the number’s on your insurance card) you can work with your healthcare provider or even the testing lab to get:

  • The exact name of the genetic test
  • The specific gene(s) the lab is testing
  • CPT or HCPCS codes (the procedure codes a hospital or lab uses to bill your insurer)
  • ICD codes (the diagnosis codes included with the test order)
  • The full name of the lab, hospital, or other facility that will send the claim to your insurer

More information will help the health plan representative understand your benefits, policy criteria and network status. If you can’t gather all this information, don’t sweat! Try to at least get the CPT codes. You’ll also want to verify if there are any up-front requirements (things like genetic counseling or pre-authorization) that affect your coverage.

What is pre-authorization?

Pre-authorization means that the insurer must validate whether a procedure, service, or medication qualifies as necessary under the specific terms of your policy. Sometimes the insurance company requires this.

What this means for you:

  • If your insurer requires pre-authorization and you DO NOT get it prior to your test, your claim can be denied even if the test was medically necessary
  • It’s critical to check whether your insurer requires pre-authorization PRIOR TO your test

You can call the number on the back of your insurance card to find out if your plan requires pre-authorization and what the criteria are.

What are diagnosis codes and procedure codes?

Your healthcare provider, lab, or genetic counselor uses diagnosis codes (ICD codes) to tell your insurer why a specific procedure – a genetic test, for instance – should be performed.

A procedure code (the CPT or HCPCS code) is a unique code tied to a specific procedure for billing purposes. The unique procedure code lets your health insurance company understand exactly what procedure or test will be performed and why.

The insurance companies use these codes to determine eligibility, coverage and cost allowances. See How do I pre-verify my insurance coverage above for more information about getting these codes from your healthcare provider, testing lab, or genetic counselor.

Understanding Your Costs

What are co-insurance, co-payments, and deductibles?

They’re all pieces of what are called out-of- pocket costs, a way for health insurers to share the overall cost of medical procedures with the people their policies cover.

Your deductible is the amount you pay before your insurer starts to pay. In most cases, you need to reach your deductible amount before your insurer will start paying. Remember: your deductible is per year, not per procedure.

Coinsurance is the percentage (typically 10%-30%) you pay toward a covered healthcare service.

  • If your policy’s coinsurance is 10% and a procedure costs $1,000, you pay $100 and insurance covers the remaining 90%. Note that this example assumes you’ve already met your policy’s deductible.

Your co-payment (or co-pay) is a fixed dollar amount you pay when you receive medical care. The co-pay usually depends on the type of service you receive.

  • For example, your policy may specify a $20 co-pay for a general doctor visit, but a $200 co-pay for an emergency room visit.

Remember: Your policy may not include all of these cost examples, and the dollar amounts here are meant to illustrate concepts, not your actual policy. Make sure to check your policy for your specific deductible, coinsurance, and co-pay amounts.

What is an Explanation of Benefits (EOB)?

An EOB is a statement from your insurer that outlines several important pieces of information:

  • The total charges for a procedure
  • How much your insurer paid toward those costs
  • Costs that have been discounted
  • The amount you will owe, based on your policy’s co-insurance, co-payments, anddeductibles

Remember: An EOB is not a bill. Instead, it’s a notification that gives you detailed information about how your insurer processed the claim. Any bills you’re responsible for will come directly from your healthcare providers or from the lab that performed your test.

What does it mean to be In-Network (or a Preferred Provider)?

These are groups of doctors, hospitals, labs, pharmacies and other providers that have worked with a health insurer to standardize their rates and care policies for that insurer. A provider that is part of this network is usually referred to as “in-network” or a “preferred provider,” depending on your policy. Providers who are not included are considered “out of network.”

Tip: You’re likely to pay less for in-network providers than for out of network providers. Your healthcare provider or testing lab can verify if they’re in your insurer’s network.

How does the Affordable Care Act affect genetic testing?

The Affordable Care Act makes coverage for genetic counseling and BRCA testing mandatory – with no out-of- pocket cost – for women whose healthcare provider determines they are eligible according to the USPSTF guidelines.

What this means for you: If your healthcare provider determines you meet the guidelines, genetic counseling and/or BRCA testing may be covered under your insurance plan with no cost-sharing.

Getting Help

Who can help me figure out my insurance policy?

Start with your healthcare provider or genetic counselor and your health insurer. But remember, each of them are looking at genetic testing through different lenses and you may need to connect the dots to piece everything together.

Your healthcare provider or genetic counselor will have the procedure and diagnosis codes for your test that your insurer needs to validate coverage. Be sure to get these codes before calling your insurer.

Helpful tips:

  • Ask if your healthcare provider or lab will contact your insurer directly to validate coverage.
  • Your policy may require prior authorization before your test. If it does, find out if your healthcare provider or testing lab will be submitting the information on your behalf.

Your health insurer’s customer service reps know a great deal about the company’s policies, but will need additional information -like your procedure and diagnosis codes – to help you beyond your policy’s general outlines.

What can I do if my insurance claim was denied?

If your claim was denied, your first step is contacting your health insurance company to understand why – and to find out if there are options for reversing the decision. Sometimes it is as simple as having your healthcare provider update a procedure or diagnosis code. Your healthcare provider or genetic counselor can also write a Letter of Medical Necessity to explain the reason for the test.

If that doesn’t work, another option is the Patient Advocate Foundation, a non-profit organization offering arbitration, mediation and negotiation services to help individuals settle issues with medical debt and related issues.