It pays to understand your health insurance policy. Learning to speak the same language as your insurance carrier is a must for people with a medical condition like desmoid tumor.

Health insurance programs can seem overwhelmingly complicated. But if you know how to make sense of your plan, you can better predict the actual dollar amount to budget for health care costs. Empower yourself by learning some key insurance terms and take control before a surprise medical bill arrives in the mail.

1. Preauthorization or Precertification

Many insurance companies require approval before they agree to pay for specific screenings or treatments. Preauthorization, or precertification, is the process of asking for permission before you schedule a medical service. This gives your insurance carrier advanced notice about the care you’re planning to receive. They’ll review your case and decide if they feel the treatment or procedure is medically necessary. Then, they’ll let you know whether your plan covers all, some, or none of the cost.

People with desmoid tumors may need to request preauthorization for certain medical procedures, such as periodic imaging to monitor their tumors, or treatments, such as targeted therapies. Plus newer drugs are often more expensive, and may require preauthorization by your insurance company.

Some targeted therapies used to treat desmoid tumors are used off-label, meaning they are approved by the U.S. Food and Drug Administration for some conditions, but not specifically desmoid tumors. This can sometimes pose extra challenges for preauthorization. Talk to your desmoid tumor specialist team if you have questions about insurance coverage for treatments used off-label.

Without preauthorization, you risk paying for a medical cost entirely out of pocket. Understanding your insurance plan’s preauthorization policy can help you avoid unexpected expenses, so you know what to expect before you get charged with the bill.

2. Appeal

An appeal is a formal request to your insurance company to review a coverage decision. For instance, you or your health care provider may submit an appeal for unexpected charges associated with biopsies, imaging tests, or surgical procedures. You might file an appeal if a preauthorization or a claim is denied. Appeals allow you to ask again when you feel the medical service is necessary and should be covered.

You can request a document called an “explanation of benefits” to get a breakdown of your insurance plan’s costs and coverage and learn more about how the company came to its decision. After reviewing this document, you may feel your insurance company’s decision is inaccurate or unjustified. Appeals are a way to challenge these decisions. The appeals process lets you advocate for coverage to get the care you need for desmoid tumors.

3. Deductible

A deductible is the amount of money you have to pay out of pocket for covered medical services before your insurance company helps with the bill. Different plans have different annual deductibles. Usually, insurance plans with lower deductibles are more desirable, but sometimes the monthly premium (the cost of having insurance) for a low-deductible plan is more expensive. Each year, your deductible resets, meaning you’ll have to pay the deductible amount again before your insurance starts paying for covered services.

Deductibles can significantly impact health care expenses, especially when managing diseases like desmoid tumors. You’ll spend your own money first on the costs associated with tests to diagnose and monitor your condition. Expenses associated with your health care, such as periodic imaging, can add up. Knowing your deductible amount in advance will help you plan for the cost of medical care throughout the year. It may give you some peace of mind to know when your insurance carrier will start contributing.

4. Coinsurance

Some insurance plans also include something called coinsurance. Coinsurance is the percentage of medical bills you must pay after meeting your deductible. It’s a cost-sharing arrangement between you and your insurance company. That means your additional medical expenses aren’t free even if you meet your deductible. You pay a percentage of covered expenses; your insurer pays the rest.

Coinsurance can significantly impact out-of-pocket costs, especially for expensive medical procedures. Knowing your coinsurance rate helps you anticipate health care expenses and budget accordingly for ongoing care, like follow-up appointments with your desmoid tumor care team.

5. Copay

A copay is a fixed amount you pay for a covered health care service or treatment. Copays are paid at the point of service, similar to checking out after shopping at a store. Your insurance plan should have a set copay for specific services. Examples could look something like $40 for a primary care visit, $60 for a specialist visit, and $20 for prescription drugs.

During your care for desmoid tumors, you may be referred to specialists like dietitians to help manage the side effects of treatment. Understanding your expected copay makes health care costs more predictable. You can call your insurance carrier to learn what copays are associated with your health plan.

6. In Network vs. Out of Network

Some hospitals, pharmacies, and doctors have a special agreement with your health insurance company. These “in-network” facilities or providers are contracted to provide medical services at a set rate already agreed to by your insurance company. Cancer centers or providers that aren’t part of the agreement are considered “out of network.” It’s important to know that different health care providers in the same medical practice might not all be in the same networks.

You may have to pay more for medical care when seeing a provider or visiting a hospital that’s out of your network. Visiting in-network providers usually means a lower rate. Most insurance companies allow you to search online for medical services in your plan’s network. You can also call the number on the back of your insurance card to find out if specific health care professionals or facilities are in-network or not.

Desmoid tumor specialist care may not be available in-network, especially if you live far from a sarcoma center. Explaining the situation to your insurance company can help you find solutions that make getting your treatment more manageable.

7. Tax-Advantaged Savings Account

Tax-advantaged savings accounts are bank accounts you can use to pay for medical expenses. Common accounts include a health savings account (HSA) and a flexible spending account (FSA). You must have a high-deductible health plan, or HDHP, before qualifying to set up an HSA.

If you get health insurance through your employer, they may agree to add money to your account each year as part of your employee benefits. Unlike an HSA, which you own, an FSA is owned by your employer. HSAs roll over from year to year and stay with you even if you leave your job. However, the money in an FSA may expire at the end of each year, so you’ll need to “use it or lose it.” In addition, FSA money goes back to your employer if you leave your job.

Money in these accounts may be used for various health-related costs, called qualified medical expenses. People use them for things like prescription medications, doctor’s visits, eyeglasses, and sometimes over-the-counter products like sunscreen and multivitamins. FSAs can never be used to pay your health insurance monthly premium, but in certain circumstances, an HSA can.

Tax-advantaged savings accounts are beneficial because they reduce your taxable income. That means the money you put in your account is money you don’t have to pay taxes on. These accounts are especially helpful if you end up in the emergency room or want to schedule an office visit with an out-of-network provider. Since treatment and monitoring for desmoid tumors can be costly, you should make every effort to contribute to a tax-advantaged savings plan if you have one available to you.

Talk With Others Who Understand

MyDesmoidTumorTeam is the social network for people with desmoid tumors and their family members. On MyDesmoidTumorTeam, members come together to ask questions, give advice, and share their stories with others who understand life with desmoid tumors.

Do you feel you understand your health insurance coverage well? Do you have any tips for others about navigating health insurance for desmoid tumor care? Share your insights in the comments below, or start a conversation by posting on MyDesmoidTumorTeam.