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Navigating the Insurance Maze

Navigating the Insurance Maze
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Healthcare costs are a key concern for people with cancer. Patients and family members need to determine how they will pay for treatments. Some patients do not have health insurance. Even for those with coverage, certain treatments and charges may not be included or paid in full. Patients may need help filing or appealing health insurance claims. Additionally, patients need to plan for indirect costs, including lost time from work, added child care and transportation and travel expenses.

There are steps you can take to manage your finances before, during and after treatment. For example, you can:

  • Speak with your physician and ask for a timeline for your treatment
  • Learn your insurance plan’s oncology benefits, mail-order pharmacy benefits, preauthorization, referral and claims appeal rules
  • Assess your anticipated medical expenses and whether your income might be reduced
  • Consider reducing unnecessary expenses
  • Speak with creditors early if you expect difficulty making payments
  • Check to see if you have home mortgage or car payment insurance to help cover expenses during your illness
  • Take advantage of disability plans if needed during your treatment and recovery
  • Seek access to co-payment programs that help insured patients meet their pharmaceutical co-payment expenses

Health insurance helps pay for costly medical treatments and can protect patients and their family from financial hardship. There are different types of private and public health insurance programs. Some people have private health insurance coverage either through an employer (often called a “group plan”) or through an individual policy that they have purchased. Some patients qualify for public or government-funded health insurance programs, including Medicare or Medicaid. The eligibility requirements and enrollment process can be complicated, but financial case workers and social workers can advise and help patients through the process. The single most important consideration for enrolling in public programs is to apply as soon as patients think they may qualify for programs. Many programs have waiting lists or waiting periods before covered benefits and services take effect.

Millions of people living in the United States do not have health insurance or do not have enough medical coverage. Some people may lose their insurance coverage or let it lapse when they leave or change jobs. Others who cannot afford the cost of private insurance may not realize that they qualify for government programs or other types of assistance. Or, patients may find out after they are diagnosed with cancer that their insurance does not cover the prescription drugs or treatment they need.

It is important for patients with health insurance to know what is covered and how to protect their benefits. This is not only important for newly diagnosed patients, but also for survivors who will need follow-up visits.

There are steps that patients and family members can take to manage their health finances and get the most from their coverage. They can:

  • Keep a copy of all claims and related paperwork, such as letters of medical necessity, bills, receipts, requests for sick leave, as well as a written record of phone conversations with insurers
  • Check health policies often to determine what services and medications are covered
  • Obtain proof of previous health insurance coverage from former employer and/or insurers
  • Pay premiums on time and in full to avoid lapse in coverage
  • Learn what to do if a claim is denied
  • Know the laws designed to protect patients and provide continuation of medical coverage (for example, COBRA, HIPAA, Family and Medical Leave Act, Americans with Disabilities Act)

Cancer survivors who lose, leave or change jobs may be eligible to remain in their employers’ plan under COBRA, a federal act that requires some companies to offer continuous health coverage for up to 18-36 months. Even though individuals must pay the entire premium (including the portion that the employer used to pay on their behalf), COBRA may be a better choice than an individual medical insurance plan. The COBRA plan may not be the least expensive option but is will provide continuation of coverage.

Feel free to contact the social worker or financial counselor at the oncology clinic for assistance in answering your questions or directing you to the appropriate resources. The following websites are resources to guide you if you have insurance questions as well:

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