The short answer
It is normal to feel confused about what your health insurance covers. Learning a few key terms — copay, deductible, coinsurance — and calling your plan's benefits coordinator can help you avoid surprises. Explanation of Benefits forms are not bills. A social worker or your plan's case manager can help.
It is normal to feel confused about health insurance — you can ask for help.
A copay, a deductible, and coinsurance are three different kinds of costs to know.
Call your plan and review what is covered before your care begins.
An Explanation of Benefits (EOB) is not a bill — it is a summary from your insurer.
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The full explanation.
The simple version
It is completely normal to feel confused about what your health insurance covers. Insurance takes time and effort to understand, and doing it while you are going through cancer care can feel like a lot. The good news is that a few key ideas — and a phone call or two — can help you avoid surprises and feel more in control.
Start by calling your plan
The National Cancer Institute suggests calling your health insurance company and asking to speak with a benefits coordinator. Have your policy in hand. Ask which tests, treatments, and drugs are covered and which are not, and whether your plan will cover any specialists your doctor might refer you to.
Knowing what is covered before your care begins helps you plan ahead.
The words that describe your costs
Three terms describe most of what you may owe:
- A copay is the amount you pay for each service, such as an appointment or a prescription.
- A deductible is the amount you pay before your plan starts paying its share.
- Coinsurance is the percentage you pay after your deductible is met — for example, you pay 20% and your plan pays 80%.
It is worth asking whether copays are due up front and how much they cost, so you can plan for payment.
An EOB is not a bill
After a visit, your insurer sends an Explanation of Benefits (EOB). This form lists the services you received and how much your plan paid. An EOB is not a bill. A separate bill may come later from the hospital or doctor. Keeping your EOBs helps you check that your bills are correct.
When a treatment is not covered
Sometimes a doctor feels you need a test or procedure that your plan does not cover. Your doctor and the hospital billing department can help. Often the doctor will write a letter explaining why the care is needed, which you then send to the insurance company. If the plan still says no, you can go through its appeals process.
Ask for a case manager
You can ask the insurance company to assign you a case manager. That way you can talk with the same person each time you have a question or concern, instead of starting over with someone new.
Medicare, Medicaid, and if you do not have insurance
For questions about Medicare, you can visit Medicare.gov or call 1-800-MEDICARE. For Medicaid, which is run by each state, you can visit Medicaid.gov. If you do not have insurance, HealthCare.gov lists coverage options. And if you cannot afford insurance and do not qualify for Medicaid or Medicare, you can ask hospitals and clinics about charity care and sliding-scale programs, where fees are based on your income.
You do not have to sort this out alone — a hospital social worker or financial counselor can help.
Protection from surprise bills
The No Surprises Act bans surprise bills for emergency services, and for other care you receive from out-of-network providers while you are in an in-network setting. It is one of the protections that can shield you from unexpected costs, so it is worth knowing about if a bill looks larger than you expected.
Ask how and when to pay
It also helps to ask your plan how you should pay your balance. For example, do you file a claim yourself? Does the insurance company pay the provider first? Or do you pay the bill and then get reimbursed? Knowing the process ahead of time prevents confusion later. For a plain-language refresher on how insurance works, trusted guides such as the Centers for Medicare & Medicaid Services' Coverage to Care and MedlinePlus can help.
A note before we begin
This information is educational and is not a substitute for medical, legal, or financial advice. For your own situation, talk with your care team, a hospital social worker, or a financial counselor.
Reviewed sources
This article is based on public information from the National Cancer Institute:
Words to know
Tap any term to see what it means.
Common questions
▸What is a copay?
A copay is the amount you pay for each health care service, such as a doctor's appointment or a prescription. Your plan sets these amounts. It helps to ask whether copays are due up front and how much they are before your care begins.
▸What is a deductible?
A deductible is the amount you pay for your medical care before your health insurance plan starts to pay its share. Knowing your deductible ahead of time helps you plan for costs.
▸What is coinsurance?
Coinsurance is the percentage of a covered service that you pay after you have met your deductible. For example, you might pay 20% while your insurance pays 80%.
▸Is an Explanation of Benefits a bill?
No. An Explanation of Benefits (EOB) is a form from your insurance company that lists services you received and how much your plan paid. It is not a request for payment. A separate bill may come from the provider.
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