Understand ahead of time which treatments and medical services your insurance covers, and whether you are still responsible for any out-of-pocket expenses. A good first step is to contact your insurance company using the telephone number found on the back of your insurance card.
Here are some important questions to consider and ask:
- How much is your deductible? A deductible is the amount of money you are expected to pay out-of-pocket towards your health care on a yearly basis, before your health care insurer pays. For example – if your deductible is $3,000, you are responsible for paying the first $3,000 of medical expenses at the start of each year, before your insurance begins to cover costs.
- What medical procedures and expenses does your insurance plan cover?
- Do any of your medical procedures require a co-payment? A co-payment is the amount of money you are expected to pay out-of-pocket each time you receive a particular type of health care service. For example – if your plan requires a $50 co-payment for chemotherapy, you will need to pay this amount each time you receive the treatment, even if you have already paid your yearly deductible.
- Can you appeal decisions your insurance provider makes about which medical procedures and expenses they cover?
- Does your insurance plan cover a second opinion?
- Do you need a referral to see a specialist or another doctor besides your primary care doctor?
- How can you find a specialist in network? Any health care provider who is “in network” has already contracted with your insurance company to accept specific (and often discounted) rates for their services. This can mean that your out-of-pocket expenses may be lower when you work with these providers.
- Does your plan cover costs related to travel and lodging?
- What fertility preservation options are available within your plan?
- Does your plan cover the costs of a clinical trial?
Medicare is a federal health insurance program for individuals 65 or over. It may also be available to individuals who have been deemed “disabled” by the Social Security Administration for two years. There are four components to Medicare. It’s important to know what coverage is provided in each component to receive the best care.
Part A covers certain inpatient hospitalization, hospice care and limited home care services. When an individual becomes eligible for Medicare, Part A is typically available with no monthly cost. If you have paid Medicare taxes while working, Part A doesn’t require any premium.
Part B covers outpatient services like doctor’s visits and preventive services. Part B includes a deductible (this is the amount of money you are expected to pay out-of-pocket towards your health care before your health care insurer pays) that may change year to year.
Part C (also known as Medicare Advantage) offers private health plans and can be useful for those looking for all-in-one medical and drug coverage. However, some Medicare Advantage HMOs restrict which doctors and hospitals you can use. These plans must offer at least the same benefits as other parts of Medicare that are available but have different rules, costs and coverage restrictions.
Part D (also known as Medicare Prescription Drug Plan) covers outpatient prescription drugs. Be aware of Medicare “gaps.” Even with Medicare A and B there are still “gaps” in coverage. For example, there is a 20% co-insurance fee for Part B services, and neither A nor B offers drug coverage. Some individuals choose to supplement their coverage with a retiree plan if their former employer offers one.
Learn more information on coverage and deductibles for each part of Medicare by visiting www.medicare.gov or call 800-633-4227.
When deciding on a Medicare plan, know what part(s) can work best for you. Part A and Part B can cover chemotherapy but there may be out-of-pocket costs, like a co-payment. Cancer screenings, such as colonoscopies, are also covered by Part B.
Clinical trials are research studies that evaluate new cancer treatments. Clinical trials may provide an opportunity for patients to access the latest in cancer care and help identify new therapies for people with cancer. If you are interested in participating in a clinical trial, Part A and/or Part B may cover some of the costs. It may be helpful to ask before enrolling in a clinical trial what your Medicare plan will cover.
Before seeing a doctor, call ahead to make sure the doctor accepts Medicare. You can learn more about Medicare coverage options and find plans in your area by visiting the Medicare website (www.medicare.gov). An oncology social worker at CancerCare can also help. Call 800-813-HOPE (4673) and speak with a CancerCare professional oncology social worker who can help you understand Medicare and your insurance options.
Medicaid is a state-administered health insurance program that provides free or low-cost coverage to millions of Americans. In the 30 states that have chosen to “expand” Medicaid, it covers all children and adults below 138% of the Federal Poverty Level, which for 1 person in 2016 is approximately $16,240. In the remaining 20 states, it only covers low-income families with children, pregnant women, the blind, and the disabled. To see if your state has expanded Medicaid, and to apply, visit www.healthcare.gov.
When You’re Uninsured
Being diagnosed with cancer and not having health insurance can bring many challenges that are stressful and emotionally difficult. Feelings such as uncertainty and anxiety are very common, but these should not keep you from getting treatment. There are ways to get health insurance or find the resources you need. Five ways to get health insurance:
Your, or your spouse’s, employer or union. If you or your spouse has a job that offers health insurance, ask if you’re eligible to receive it or buy into it. If you had insurance but lost your job within the last 60 days, ask if you’re eligible for COBRA. COBRA is a law that lets you keep your insurance for 18 months, sometimes longer. You pay the full cost.
Your school. If you are currently a full-time or part-time student, check with your college or university to see if you can get coverage through them.
Medicaid. To see if your state has expanded Medicaid, and to apply, visit www.healthcare.gov.
Medicare. If you are 65 or over, or have been deemed disabled by the Social Security Administration for two years, you may be eligible for Medicare. Contact www.medicare.gov for more information.
Purchase it on your own. You can buy insurance either directly through an insurance company, or through your state’s Marketplace/Exchange. If you buy it directly through an insurance company, you will not be eligible for discounts based on your income. If you buy it through your state’s Marketplace/Exchange, your income will be taken into account, and you may receive an immediate subsidy, which will lower the cost of your premiums, and possibly your deductibles and co-pays as well. To find your state’s Marketplace, go to www.healthcare.gov. Please note: whether you buy it directly from an insurance company or through the Marketplace, you can only buy insurance during Open Enrollment. Open Enrollment occurs once a year, generally between November and January. There are a few exceptions to this rule—if you lose your job-based coverage mid-year, get married, have a baby, move to another county or state, or become eligible for Medicaid, you are eligible for a special enrollment period. For more information on special enrollment periods, visit www.healthcare.gov.
The Affordable Care Act
Millions of people have been able to enroll for health care coverage through the Affordable Care Act (ACA).
Key Features of the Affordable Care Act:
- People with pre-existing conditions, including cancer, can buy health insurance through online insurance Exchanges, also known as Marketplaces. Exchanges allow you to compare plans by benefits, price, provider participation and pharmaceutical coverage.
- Health plans must cover essential health benefits including cancer treatment and follow-up care.
- Health plans must also cover check-ups and preventative services (e.g., cancer screenings, including mammograms and colonoscopies), and there are no co-payment or deductible costs. If you’ve had a history of cancer, these tests may be considered diagnostic, not preventative, and you may be responsible for the cost. Please check with your insurer.
- Young adults can stay on their parent’s insurance plan until age 26.
- Insurance companies cannot deny coverage to people based on their medical history or charge people who have existing health issues more.
- Insurance companies can no longer end coverage or impose lifetime or annual dollar limits on coverage because a person gets sick.
- Insurance companies are required to provide more details about their health care plans.
- Health care plans on the Exchanges limit the out-of-pocket costs and deductibles for patients.
- New rules and rights exist to help patients appeal claims that are denied.
With an uncertain future for the Affordable Care Act, people affected by cancer are understandably concerned. It’s important to stay informed and share feedback and personal experiences with elected officials. Here are resources that can help:
- Kaiser Family Foundation (www.kff.org/health-reform)
- Families USA: The Voice for Health Care Consumers (www.familiesusa.org)
- National Coalition of Cancer Survivorship (www.canceradvocacy.org)
- American Cancer Society’s Cancer Action Network (www.acscan.org/what-we-do/access-health-insurance)
- Medicare Rights Center (www.medicarerights.org)
Contact Elected Officials
- VoteSmart (www.votesmart.org)
- Social media contacts for elected officials via Triage Cancer (www.triagecancer.org/congressional-twitter-handles)
Also, you can contact your elected officials and share your health insurance concerns. To find your elected officials, visit www.votesmart.org/officials. Social media contact information for current members of Congress can be found on www.triagecancer.org/congressional-twitter-handles.