Prior authorization
Means: Insurer must approve certain procedures or drugs in advance.
Why it matters: Skipping prior auth = full claim denial. Even if your doctor says it's needed.
Fine Print / Health
Reading the Fine Print: Health Insurance Policies
Health insurance is more about the rules than the coverage. Here are the rules that catch people.
Step therapy
Means: Must try cheaper drugs first before insurer covers preferred drug.
Why it matters: Can delay treatment by months. Appeal with doctor's letter of medical necessity.
Out-of-network balance billing
Means: Out-of-network providers can bill the difference between their charge and what insurer pays.
Why it matters: No Surprises Act now bars most surprise bills, but ground ambulance and elective out-of-network are still exposed.
Formulary tier changes mid-year
Means: Insurer can move drugs to higher tiers or off formulary mid-year.
Why it matters: Your $30 copay drug becomes $200 overnight. Limited appeal options.
Deductible reset
Means: Most plans reset January 1 (some employer plans use plan year).
Why it matters: Schedule expensive procedures after meeting deductible — same year, much lower cost.
Embedded vs aggregate deductibles
Means: Family plans either have per-person AND family deductibles, or only family.
Why it matters: With aggregate, no one is covered until the full family deductible is met. Embedded is friendlier.
Network adequacy
Means: Insurer's responsibility to maintain enough in-network providers.
Why it matters: If no in-network specialist is available within reasonable distance, you can demand out-of-network coverage at in-network rates.
Special enrollment events
Means: Outside open enrollment, only qualifying life events allow plan changes.
Why it matters: Marriage, birth, job loss, moving — narrow window (usually 60 days) to change plans.