Managing Your Health Insurance
Just as you manage interactions with your healthcare team, you also manage interactions with your health insurance plan. Find out if anyone in your hospital’s billing office can answer questions about health insurance. Many hospitals have patient financial counselors who can offer advice and help you get answers to your health insurance questions. You also can ask a family member or friend you trust to help.
If you’ve been diagnosed with cancer, you may find that the health insurance plan you have doesn’t cover enough of your medical costs. It may make sense for you to consider switching to a plan that has higher premiums but covers more of your costs over the long run. If you’re covered through Medicare, you may want to consider purchasing supplemental health insurance, if you haven’t already. Without a “Medigap” policy or other secondary health insurance, you are responsible for 20% of treatment-related costs.
To make changes to your health insurance plan, you generally have to wait until an open enrollment period, which is the time of year that health plans accept new applicants. Timing can vary depending on whether you’re considering a job-based plan, a Medicare supplement, or an individual plan through the Health Insurance Marketplace.
The Cancer Support Community has partnered with other cancer organizations to create The Cancer Insurance Checklist, which can help guide you in choosing a plan on the Health Insurance Marketplace.
Here we discuss various U.S.-based resources and U.S. regulations. Other countries may have different laws regulating health insurance coverage and hospital operations. If you live outside the United States, ask your doctor about resources in your country.
Health insurance out-of-pocket costs
Examples of potential out-of-pocket expenses include the following:
Deductible: This is the amount you have to pay for medical services each calendar year before your health insurance plan kicks in to cover a portion of your costs. Routine preventive care such as physicals and screenings may be covered no matter what. But for other types of services, you have to pay for a certain amount before your health insurance plan starts covering costs. For example, if your deductible is $2,000, your benefits would not kick in until you pay $2,000 in medical expenses. If your deductible is $5,000, you’d have to pay $5,000 before benefits kick in.The clock resets with each new calendar year. If you meet your deductible for the year and your plan kicks in, the coverage turns off on the first day of the new year, until you meet your deductible again. Since cancer treatment takes place over time, the costs can add up quickly from year to year — especially if your plan has a high deductible.
Co-payment: A co-payment, or co-pay, is a fixed fee you pay every time you visit a doctor’s office, get lab work done, or fill prescriptions. If you haven’t met your deductible, you cover the cost of the service set by your health insurance plan. After you meet the deductible, you cover the co-pay. Depending on your health insurance plan, co-pays can range from $20 to $60. Your plan also may have different co-pays for visits to specialists, other healthcare providers, lab tests, or medications.
Coinsurance: Coinsurance is the percentage you pay toward medical services after you’ve met your deductible. Depending on your health insurance plan, you can be responsible for covering 10%, 20%, or even 30% of your medical costs, and the health plan covers the rest.
Medications: Health insurance plans often have a list of medications that the health plan covers, known as a formulary. The formulary varies by the type of health insurance plan you have and by the types of medications you need. Some health plans won’t cover a brand-name medication if a generic version is available. Other health plans won’t cover more expensive chemotherapy medications — such as oral versions of drugs — if cheaper options are available. Some health plans have “tiered” lists of medications, with higher-tier drugs requiring a higher co-pay or coinsurance. It’s a good idea to get familiar with your plan’s formulary, or ask someone to help you, if you need it.
Be aware that your plan also has an out-of-pocket maximum for the year. Once the deductible, co-pay, and/or coinsurance payments hit that maximum, your health plan pays 100% of medical services that your health plan covers. As with the deductible, the clock resets with each new calendar year. Out-of-pocket maximums can vary across different health insurance plans, but they are federally regulated. This means that the federal government decides the highest amount any health insurance plan can set for individual plans and family plans. Out-of-pocket maximums increase annually. The U.S Department of Health and Human Services publishes updated out-of-pocket maximums each year for individual plans and family plans. It is possible that your health plan’s out-of-pocket maximum may be lower than the highest limit set by the federal government.
Out-of-network costs: Some health plans have a list of approved or preferred providers who participate in the health plan’s network. If you go “out of network” to a doctor or other healthcare provider who is not on the list, you pay more than you do if you stay in network. You may even have to pay the entire amount when you go to an out-of-network provider. Out-of-network costs do not count toward your out-of-pocket maximum. Out-of-network expenses sometimes can crop up unexpectedly during hospital or treatment visits, for example, if a physician or other healthcare provider sees you but isn’t part of your health plan’s network. It’s a good idea to make sure that each person in your medical team is in network.
Having a clear understanding your health insurance plan can help you feel more in control as you begin treatment for breast cancer. Even if you find that your out-of-pocket costs are higher than you expected, you can take steps now to get help.
“Many people have high-deductible health plans, where they might have to meet as much as $5,000 in costs before health insurance kicks in. And even then, health insurance might cover only 80% of their costs. So it can add up quickly.” — Annette Hargadon, CRNP, breast surgical specialist, Lankenau Medical Center, Main Line Health, Wynnewood, Pa.
Tips for working with your health insurance company
Here are some tips to help you understand your health insurance plan and work with your insurance company:
Make sure you have your health insurance company’s accurate contact information and an up-to-date copy of your health plan’s basic information. Sometimes called a summary plan description, the health plan’s basic information tells you how the plan works, the benefits the plan offers, and how you can file a claim.
If you buy your own health insurance because you don’t have coverage through your employer or your spouse’s employer, make sure you pay your premiums on time.
Ask your health insurance company if it can assign you a case manager so you can speak with the same person each time you call.
Take advantage of your health insurance plan’s website. By registering for online access as a member, it’s often easy to see the details of your plan, the healthcare services you’ve received, and how much your health insurance company has paid versus what you owe.
Your doctor may want to refer you to one or more specialists, such as a radiation oncologist or a reconstructive surgeon. Make sure these specialists participate in your plan’s network. For any in-hospital treatments, tell your medical team that you want to make sure all providers who care for you participate in your plan’s network. People are sometimes surprised to get large bills because the healthcare providers who saw them in the hospital aren’t part of their health plan’s network.
For any follow-up testing, such as imaging or lab tests, make sure you’re going to a facility that is part of your health plan’s network.
Find out which procedures require a co-payment and/or coinsurance and how much you need to pay.
Keep detailed records of all the claims you submit and make note of when you submit them, whether the claims are still pending, and when the claims have been paid. The health plan’s website may help you track some of this information.
Keep copies of any and all paperwork related to your treatment, diagnosis, and health insurance claims, including:
requests for sick leave
letters from your doctors, employer, and health insurance company
letters you write to your doctors, employer, and health insurance company
summaries of phone calls to your health insurance company, including the date, time, and name of the person who spoke with you
Find out how you should pay for treatment. Does your doctor’s office or hospital bill the health insurance company first? Or do you pay the bill upfront and then get reimbursed?
If your health insurance company requires you to submit bills, try to send them in as soon as you get them. If you’re recovering from treatment, ask a loved one or friend you trust to help you.
If your health insurance company denies a claim, ask your case manager why your claim was denied and if and how you can file an appeal. You can also speak with the patient financial counselor or the person who handles health insurance claims at your hospital or doctor’s office. This person often can help with the appeal process and provide any documentation your health insurance company requires. Keep records of all your communications as you go through the appeal process. If you find the back and forth frustrating, ask a loved one or friend you trust to help you.
It’s a good idea to ask about coverage for services such as home health visits, palliative care, physical therapy and rehabilitation, and mental health care and counseling — all of which may be important to your recovery.
Understanding COBRA benefits
In the United States, if you change jobs while you are being treated for breast cancer or you lose your health insurance coverage because you’re working fewer hours, COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986) allows you to remain temporarily covered by the health insurance plan you had with your former employer. You also are eligible for COBRA if you were previously covered under your spouse’s health plan and you get a divorce, your spouse passes away, or your spouse stops working or works fewer hours and loses health insurance coverage. Typically, the law requires private-sector employers with 20 or more employees or state or local governments to offer COBRA to former employees who are eligible. The law does not apply to health plans maintained by the federal government, churches, or certain church-related organizations. Some states do require that companies with fewer than 20 employees offer COBRA to former employees who are eligible. Check with your state for details.
The amount of time you can continue to receive health coverage through COBRA depends on why you lost your health insurance:
You can get up to 18 months of COBRA coverage if you or your spouse — if you were previously covered under your spouse’s health plan — stop working or reduce the number of hours you work.
You get up to 3 years of COBRA coverage if you get a divorce or your spouse passes away.
COBRA coverage isn’t automatic. It’s important to know that you have to request coverage within 60 days of getting a written COBRA notice. It may not be within 60 days of when you stopped working or when you began to work fewer hours. It’s a good idea to talk to your human resources representative as soon as you have a COBRA “qualifying event,” such as having to work fewer hours. You also may want to talk to your health insurance company to find out what you and your former employer need to do to make sure you have uninterrupted coverage. Get more information on COBRA benefits.
COBRA rates are usually much higher than the rates you pay when you are covered through your employer (or your spouse’s employer). If cost is a concern, you can review Health Insurance Marketplace options on HealthCare.gov or by calling 1-800-318-2596 (TTY 1-855-889-4325). You may qualify for special enrollment in a Marketplace plan if you lost your job-based coverage in the past 60 days or expect to lose health coverage in the next 60 days. Some people use COBRA as a “bridge” until they can find a Marketplace plan that meets their needs.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) guarantees that, if you switch jobs, you can get health insurance through your new employer as long as:
you’ve had health insurance for at least a year and haven’t lost health coverage for more than a couple of months
your new employer offers group health insurance.
HIPAA also guarantees that an employer-based plan and an individual plan can’t deny you coverage because of a pre-existing health problem. Get more information on HIPAA.
If you have disability insurance, you may have to decide if and when you need to use it. Your decision depends on the type of treatments you need, how long you need to receive treatment, and the specifics of your diagnosis.
Find out if you are eligible for short-term disability insurance and the benefits it offers. In some states, laws require that most employers provide short-term disability benefits for up to 26 weeks. Short-term disability usually pays you a percentage of your salary for a specified period of time. Some policies may require that you use up all your sick time and vacation days before you receive any short-term disability benefits. Talk to your human resources representative so you know exactly where you stand and what to expect.
Your employer isn’t required by law to offer long-term disability insurance. Still, many medium- and large-sized businesses offer long-term benefits for at least 5 years. A typical long-term disability policy pays about 60% of your salary and starts when you have used up your short-term disability benefits. You can receive long-term disability benefits for a range of 5 years to life. Long-term disability policies vary widely. Talk to your human resources representative and find out if you’re covered, what is covered, and how long you can receive payments. It’s also important to know if your employer’s plan takes other benefits you may be receiving — such as Social Security disability benefits — into consideration when figuring out how much long-term disability benefit to pay you.
— Last updated on January 21, 2022, 9:20 PM