Healthcare is … confusing. (Understatement of the year.) Between the need-to-Google terminology and the ever-changing rules, it can be a headache to understand—but it’s also crucial to know how your plan works. Knowing your coverage makes it easier to choose the right plan *and* take full advantage of your current benefits. (You’re paying for them, after all.)

It also helps you get the healthcare you need without surprises: providers like Tia often only receive basic summaries of a patient’s insurance benefits, but you have access to more detailed information about what’s covered—and what’s not.

That’s why we recommend carving out time to call your insurance provider, ask some important questions, and really get to know your plan. Don’t worry: we’re here to walk you through it, step by step!

Before you call: what to prepare

Before getting on the phone with your insurance provider, take a few minutes to get ready—and a few deep breaths. Here’s what we recommend:

• Gather your plan documents
  • Your current insurance card
  • A copy of your plan’s Summary of Benefits and Coverage (SBC)
  • Recent Explanation of Benefits (EOB) statements, if applicable
  • List of past and upcoming medical appointments or treatments, including any ongoing prescriptions
• Review your medical history and think about the year ahead
  • Make a list of any ongoing health conditions (e.g., fertility treatments, chronic illness management) and medical needs for the upcoming year (e.g., planned surgeries, mental health support, family planning).
  • Determine how your coverage needs might change based on lifestyle shifts, like starting a family or taking a new medication.
• Get ready to take notes:
  • You’ll be getting a lot of info, so having a pen and paper or your Notes app handy will make it easy to record what you learn—and reference it later.

On the phone: key questions to ask your insurance provider

Getting a thorough understanding of your coverage involves asking some nitty-gritty questions. We’ve broken them down into three buckets—from general to more specialized—so you can pick and choose what’s relevant to you. 

Coverage & network questions

Getting these answers will help you learn how your benefits work—and how to make the most of them. 

• General coverage
  • Does my plan have copays? What general services will I pay towards my in-network deductible for?
  • What is my deductible? How much do I need to pay out of pocket before my plan starts covering care?
  • What are my out-of-pocket maximums? What is the most I’ll have to pay in a year? Does my maximum out-of-pocket include copays?
  • Is there a co-insurance rate after my deductible is met? How much will I have to pay per service (e.g., 20%)?
  • Do I have to select a primary care provider (PCP), or can I see any doctor in the network?
  • What are the coverage limitations on my plan?
• Network & providers
  • Is my current doctor or specialist in-network? How can I find out if my preferred providers are covered?
  • What Tia clinic providers are in-network? What locations and addresses are in-network for those providers?
  • Do I need a referral to see specialists, such as dermatologists, neurologists, or mental health professionals?
  • What are the rules for out-of-network providers? Will I be reimbursed, and if so, at what rate?
  • How can I confirm if a specific hospital or facility is covered for planned procedures?
• Prescription coverage
  • Are my prescription medications covered? Is there a formulary or list of covered medications that I should review?
  • What happens if my prescription is not covered? Can I get it approved with prior authorization, and how does that process work?
  • Is there a mail-order pharmacy option that might be more affordable?
  • What are the co-pay amounts for different types of prescriptions, such as generics vs. brand-name drugs?

Services & treatments questions

These q’s help you dive deeper into what types of services are covered by your plan.

• Preventive care
  • What preventive services are fully covered under my plan? Does this include annual physicals, vaccines, screenings (e.g., mammograms, colonoscopies)?
  • What preventive lab work is covered by my plan?
  • Are preventive annual visits and counseling covered at 100% by insurance or will I have a cost share?
• Specialty services
  • Are mental health services covered, and if so, what types of care (e.g., therapy, psychiatry)?
  • What alternative treatments are covered? Does the plan include acupuncture, chiropractic care, or nutrition counseling? Are there limitations on when these services will be covered, such as needing pre-authorization or must be related to a certain diagnosis?
• Not covered/out-of-pocket costs
  • What treatments or services are explicitly not covered by my plan (e.g., cosmetic surgery, fertility testing or treatments)?
  • Are there any limits on covered treatments, such as the number of visits or treatments per year for things like physical therapy or mental health?

Chronic conditions & unique needs questions

If you or a family member have a chronic illness or require specific medical treatments, these questions can help you figure out what’s covered. 

• Chronic disease management
  • Does the plan cover care for chronic conditions like diabetes, hypertension, or asthma? What specialists are covered?
  • What home health services are available, if needed?
• Family planning & fertility
  • What fertility treatments are covered (e.g., IVF, egg freezing, hormone therapy)?
  • Are maternity services fully covered, including prenatal, delivery, and postnatal care?
• Telehealth & virtual care
  • Does my plan cover telehealth appointments? What types of care can I access virtually (e.g., primary care, therapy)?

Wrapping up: document your conversation

Once you’ve gotten your questions answered, finish up the convo with these requests. 

• Ask for a confirmation number or a reference to your call.
• Request an email follow-up that outlines any agreements or changes made during the call.
• Keep notes for future reference, including the name of the representative you spoke to.

Next steps: after your call

Just a few more steps ‘til this major to-do is done. 

• Review the Summary of Benefits
  • Double-check the Summary of Benefits and Coverage after your conversation to ensure everything aligns.
  • Confirm any details in writing, particularly for complex services or treatments.
• If necessary, follow up
  • If something is unclear, don’t hesitate to call back and ask for further clarification.
  • Ensure you’re fully comfortable with your coverage before making any changes or final decisions.
  • Message or call your Tia care team to review this information if you have any questions or want to know more.

Take advantage of Open Enrollment—we’re here to help

You just received a ton of information from your insurance provider—which means you’re more empowered to make educated decisions about your healthcare. Don’t forget: we’re here to help make sense of what you learned!

If you have questions or want to know how what you learned might impact your healthcare at Tia —or from any provider—just reach out.

Tia members can chat with their Care Coordinators for more info, and non-members can give us a call at (888) 808-2069.

From providing expert primary care, gynecology, mental health, acupuncture, and skin care to demystifying insurance, we’re all about empowering women to make informed decisions and take care of their whole health—in Open Enrollment season and beyond.