Make Sense of Insurance Matters
While insurance makes paying for cancer care easier, it’s unlikely that even the best health insurance plan will cover every cancer-related cost. According to a report based on calls to the Patient Advocate Foundation, the most common insurance-related problems for cancer patients are:
- High out-of-pocket and prescription costs
- High cost of insurance premiums when unable to work
- Challenges gaining access to preferred treatment options
- Confusion navigating insurance pre-authorization requests and denials
In one survey by the American Cancer Society, about 5 percent of insured people with cancer said they delayed or opted against treatment because of cost. Don’t be part of that 5 percent: Learn the ins and outs of your insurance plan to make sure you get the coverage you need.
Whether you are seeking preventive care, care after an accident or injury, or treatment for an ongoing illness or disease, health insurance helps patients find care and afford the care provided by their doctors. Health insurance ultimately helps patients pay the cost of their medical care by contributing financially toward a portion of the total bills.
Many Americans’ health insurance is sponsored by an employer, and today more and more employees are being asked to pay a larger portion of the premium to maintain that coverage. Your ability to afford premiums and other cancer-related expenses can be difficult during your journey with the disease. Although it may be a financial challenge, try to pay your premiums in full and on time so that you’re not dropped from your plan. If you need to change insurance plans, make sure the new one takes effect before the previous policy expires.
Additional challenges present themselves if you’re unable to work for a period of time, making it difficult to keep your employer-sponsored insurance. However, two federal laws offer some protection for keeping your health insurance in place: the Family and Medical Leave Act (FMLA) and the Consolidated Omnibus Budget Reconciliation Act (COBRA).
As part of the Affordable Care Act, everyone is required to purchase a health insurance plan to cover their medical needs or face a financial tax penalty. If you do not have insurance, try to get coverage as soon as possible. Under the Affordable Care Act, the government must maintain an exchange in each state, also known as a Health Insurance Marketplace, which allows people to compare and select an affordable health insurance plan to meet their needs. These marketplaces are a central point for those who do not have employer-sponsored insurance, those who have previously been denied coverage because of a pre-existing condition (such as cancer), or those who are interested in switching from their current plan. In addition, the marketplace in your state might screen you for additional resources to help make the insurance affordable, with many consumers qualifying for Premium Insurance Tax Credits that will reduce the premium cost each month. However, Health Insurance Marketplaces are only available during open enrollment periods or during periods of special enrollment applicable to specific scenarios.
Depending on your scenario, you may qualify for government-assisted health insurance, including Medicaid or Medicare. Medicaid programs are designed to help those with limited means gain high-quality care, and insurance programs are managed by each state. Review the guidelines and eligibility in your state to see if this is an option for you. Medicare is a federal health system designed for those age 65 or older or those who are disabled. To learn about the eligibility and process for qualifying for Medicare, visit www.medicare.gov.
Become familiar with your insurance plan
No matter whether you have a private insurance plan or one managed through the government, four primary types of health insurance are available:
- Health maintenance organizations (HMO) or exclusive provider organizations (EPO)
- Preferred provider organizations (PPO) and point of service plans (POS)
- Fee-for-service plans
- High-deductible health plans (HDHP)
They differ in many ways, including which doctors and hospitals are part of the plan. With HMO or EPO plans, your insurance covers you only when you are cared for by the participating doctors and hospitals within the plan network. With PPO and POS plans, you have the option of seeing a doctor not included in your network. In this scenario, your insurance provider agrees to pay a portion of the bills but you’re responsible for the remaining amount, typically resulting in a higher out-of-pocket portion. Fee-for-service plans offer even more flexibility in which doctor you can see, but you are responsible for a set percentage of every bill, and that total can fluctuate based on the care you sought that month. Depending on the cost of services you’re seeking, a fee-for-service structure could result in low out-of-pocket expenses or high costs for cutting-edge treatments or procedures. Medicare and Medicaid plans can also be structured as HMO, EPO, PPO, POS or fee-for-service.
No matter what type of plan you have, it’s crucial to carefully review your coverage and be familiar with the summary of patient responsibilities. If your plan is a high-deductible health plan, you have a set deductible that must be paid before the insurance contributes to the cost of your care. The most important details to understand are your out-of-pocket expenses and the processes for filing claims and appealing denials. This summary information is included in the paperwork sent to you upon enrollment. If you would like more detailed information that includes the specific language governing your policy, you have the right to request that from your insurer at any point. For cancer patients, understanding how much of clinical trial costs are covered by your insurance is important as you consider the factors in deciding whether to participate in a trial (learn more about the financial side of clinical trials).
For Medicaid or community-run insurance plans, this information can be requested through your insurer’s patient services representative.
The term “out-of-pocket expenses” includes the amount you’re expected to pay for services associated with your medical care, excluding your monthly premium. These include your deductible, co-pay and co-insurance, and they vary across plans. When you review your plan, look for answers to the following questions:
- What is my annual deductible?
- Do I have a separate deductible for prescriptions?
- When does my plan year start/end?
- Do I have a co-pay or a co-insurance plan?
- Is there a maximum or annual out-of-pocket limit?
- Is there a yearly limit on reimbursement for certain services?
In addition, review the list of covered services so you know exactly which tests and types of care are included. Also check to see if your insurer has to preapprove your cancer treatment plan and if second opinions are covered. This information can help you avoid delays in treatment.
To comply with the Affordable Care Act, your plan must include prescription drug coverage. Review the plan’s list of preferred drugs, also known as their “formulary,” and know your co-pays. Preferred drugs are those that have the highest coverage by your insurer, which means smaller co-pays for you. In addition, understanding which drugs and types of drugs are included within your plan’s specialty tier (or highest tier) is important. Many cancer patients find that the newest drugs on the market are within the specialty-tier category, which will result in high out-of-pocket costs if these are prescribed by your doctor.
Knowing your plan is critical to maximizing your coverage benefits as you seek care for your cancer. Even if you realize that your plan does not cover all of your needed care at an affordable rate, it’s best to know in advance so you can budget appropriately and seek additional resources to help. If you find you need help affording your care, numerous programs, organizations and charities are available to support cancer patients with these expenses.
If you have Medicare, programs such as the Low Income Subsidy (Extra Help) can assist with costs such as monthly premiums, annual deductibles and prescription co-pays. You can learn about these programs in the “Medicare and You” handbook, which you can find at www.medicare.gov.
Always file claims and bills for reimbursement immediately, even if you’re not sure whether the expense is covered. This will prevent bills from piling up and will get you your payment as quickly as possible. If your provider is filing claims directly with your insurer on your behalf, be sure to review closely any documentation to ensure accuracy.
Following each treatment or visit to the doctor, it’s important to review each account statement you receive from your health care providers and ask about any charges that don’t look right. This will help you catch errors early and ultimately reduce the time and costs spent correcting them. You have the right to request additional clarification on any element within your bill that you don’t understand.
In addition, when you receive Explanation of Benefits forms (EOBs) from your insurer, review them against your health care provider’s statements to make sure you and your providers have submitted all charges for reimbursement. Consider stapling or securing these together for future reference.
Be sure to keep a complete record of your claims and bills, noting which ones have or have not been reimbursed. Also keep copies of the paperwork related to your claims (EOBs, receipts, etc.) to make it easier to file an appeal if necessary.
If you have a Medicare Supplement Insurance policy (Medigap) or secondary health insurance, make sure Medicare knows about the plan, and check your Medicare Summary Notices to confirm that Medicare has passed on claims to the additional insurer after it has paid its part.
Appealing denials and uncovered services
Occasionally, your insurer may deny a claim or decline to cover a doctor-ordered test or service. Don’t be discouraged by a denial; instead, look into the problem and consider appealing it. Sometimes the denial is simply the result of improper or incomplete documentation. To appeal a denial:
- First confirm what services your insurance plan covers as written in your plan details.
- Call your insurer’s customer service department and ask for an explanation of the denial; don’t be afraid to ask to speak to a supervisor.
- Write down when you call, the name of the person with whom you speak and details of the conversation.
- If your phone call to the insurance company does not resolve the issue, ask your doctor to assist you in appealing the insurer’s decision. For example, your doctor can help by writing a letter to the insurance company to justify why the test or service was ordered. Letters from providers addressing the stated reason for your specific denial should be included within your appeal submission.
- Review the appeal instructions listed on the denial letter from the insurer, paying close attention to timelines for submission documents.
If your insurance agency denies your claim appeal for services covered within your plan language, you then have the right under the Affordable Care Act to apply for an external appeal. This is a process in which an outside organization reviews your claim and has the power to overturn the insurer’s denial, if appropriate. Check your denial notice for instructions on how to request an external review.
- Whenever possible, don’t pay for the service in dispute until the appeal process has been completed.
- If you ever feel like your insurer has treated you unfairly, contact the regulation body that oversees your type of insurance (Table 1).
- Some services and treatment options may be denied for coverage by your insurance plan because they are excluded from it. If services are not covered, it’s your responsibility to cover the full cost of these items. By knowing your plan language, submitting required pre-authorizations, maintaining regular communication with your insurer, and gaining cost estimates from your providers in advance, you can minimize unexpected bills for excluded services.
Table 1. Health insurance regulatorsVarious regulating bodies oversee health insurance plans. If you have a problem you are unable to resolve with your insurance carrier, contact the appropriate regulating body for guidance.
|Regulating body||Insurance plan||Contact information|
|Your state’s insurance department/commission||
• Individual health plans
• Marketplace plans sold in state-operated marketplaces
• Group plans (not employer-based)
• Employer-based group plans
• Medigap policies
|Depends on your state; search the Web for “[Your State] insurance commission” or “[Your State] insurance department”|
|Centers for Medicare & Medicaid Services||
• Marketplace plans sold in federally operated marketplaces
|Defense Health Agency||• TRICARE||www.tricare.mil|
|U.S. Department of Veterans Affairs||• Veterans’ health care system (including CHAMPVA)||www.va.gov/healthbenefits|
Work with people who can help
Many people can help you handle insurance matters. Doctors’ offices typically have a billing person; the cancer care team usually includes a social worker; and most medical facilities have financial counselors and patient navigators on staff. If you can, try to work with the same person for your financial help. These people can help by:
- Answering and clarifying any questions you have about your medical bills
- Providing an estimate of the cost of your cancer treatment and telling you if the cost might exceed your coverage limit
- Setting up a payment schedule for your costs with terms you can afford
- Helping you accurately process insurance claims and appeals
- Providing copies of documentation related to your bill
- Referring you to outside financial assistance organizations or charities that can help if you have difficulty paying expenses not covered by insurance
- Recommending additional resources to keep you informed about various insurance and financial matters, including publications, pamphlets, booklets and Web resources
In addition, health insurance companies often have case managers who can assist with financial matters. Call your insurance carrier and ask if a case manager can be assigned to work with you on your claims.
If you find that dealing with these matters is too draining during treatment, look to someone you trust to assist. Family members, caregivers or friends can sometimes be a great resource to help you stay organized, research and gather information, or help you initiate communication with various parties.
Don’t become discouraged if you run into roadblocks with your insurer. Instead, seek out avenues to help you overcome the roadblocks so you can continue the treatment that’s best for you.
Patient navigators and patient advocates
Patient navigators, or patient advocates, are trained experts who can help lead you through many challenges in the health care system, including insurance issues. Patient navigators are often nurses, social workers or community health workers, and some are cancer survivors themselves. They offer assistance with a wide range of services, which may include helping with insurance forms, coordinating doctors’ visits and arranging transportation to and from treatment.
You can find patient navigators in hospitals, patient advocacy organizations and the community. To find a patient navigator to work with you, call the patient relations department of your hospital or provider to see if it has a patient advocate or navigator program. You can also reach out to any of the national disease and patient advocacy nonprofits, which will help connect you to an advocate who serves patients at no cost. There are also community advocates available to help patients, some of which will charge a fee for their services. During your advocate search, be sure to clarify the specific services provided to ensure they match your needs.
Glossary of Terms
Claim: A request for payment based on the terms of your insurance policy.
Co-insurance: Generally, the percentage of medical care that you are responsible for paying after meeting your deductible.
Co-pay: The fixed amount you must pay for specific types of medical care.
Deductible: The amount you must pay before your insurance begins reimbursing fees.
Explanation of benefits (EOB): A statement provided by your health insurance company explaining what medical treatments and/or services were paid on your behalf.
Health Insurance Exchange/Health Insurance Marketplace: A central hub for those seeking health insurance where the user can review plan options, see the premium rates for each, and enroll in the plan they select.
Premium: The amount you pay each month to keep insurance coverage.
Premium Insurance Tax Credits: Tax credits from the federal government given to individuals who qualify that reduce the cost of health insurance premiums. These credits are available to use immediately to offset insurance costs, unlike other tax credits that are received when filing your taxes. Consumers whose income is between 100 to 400 percent of the federal poverty level may be eligible for these credits. These credits are also referred to as “insurance subsidies.”
Reimbursement: Compensation or repayment from your insurance company for health care services you paid for out-of-pocket.