Insurance Optimization
Making your insurance work for you, not against you.
Impact Items
- In-network providers (Crucial check!)
- Receiving pre-authorizations or referrals
- Selecting plans (Open Enrollment strategy)
- Out-of-pocket year timing
Current Events: ACA Subsidies
- "Enhanced" ACA subsidies expired at the end of 2025.
- Tax credits are now limited to 400% FPL (Federal Poverty Line).
- House passed a 3-year extension, with the Senate still negotiating.
- State Offsets: CA, CO, CT, MD, MA, NM, NJ, NY, VT, WA are offsetting this impact. Check your state's exchange.
Negotiating: "No" is not the end
Appeals
You have the right to appeal denials. Many denials are administrative errors.
Coding
Ask if a service can be coded differently (e.g., preventative vs diagnostic) if applicable.
Self-pay Discounts
Paying cash can sometimes be cheaper than the negotiated insurance rate.
Insurance Question Script
- May I have a nurse case manager assigned to me?
- May I please see a copy of my Summary of Benefits and Evidence of Coverage?
- Are there any providers involved in this treatment that might be out-of-network with my insurance?
- Can you send me a written cost estimate?
- What scenarios could lead to me owing more than my out-of-pocket max? When does it reset?
- Is this medically necessary for my cancer, and if so can it be coded that way? OR: Can it be coded as preventative?
- Does this bill match the Explanation of Benefits (EOB)? Was I billed more than allowed? Was it correctly applied to my deductible?
- Prescriptions: what tier is this drug? Is there a less expensive alternative? Do I qualify for discounted drug programs?
- Would the timing of this procedure have out-of-pocket year implications?