As a cancer patient, you may have financial resourcesavailable to you, including health insurance, government programs, disability benefits, aid from voluntary organizations, and living benefits from life insurance policies, including viaticals (viaticals are explained later on in this document). If you have no medical insurance, there are other options.
Private health insurance
Health insurance coverage helps with the medical costs that come with the diagnosis and treatment of an illness. It is important to have and keep good medical coverage. This can help you avoid financial hardship. Many patients have private insurance through employee group plans or individual plans. It is important to have accurate information and a good understanding of your financial situation and insurance coverage. It is very important to pay your monthly insurance premiums.
Types of health insurance plans
There are many types of health insurance plans. Here are very brief descriptions of the different plans:
Fee-for-service plans
If you have this type of health insurance, you can choose any doctor, change doctors any time, and go to any hospital anywhere in the United States. You pay a monthly fee, called a premium. Every year, you also have to pay a certain amount of money (known as the deductible) before your insurance will start to pay your medical expenses. After you have met your deductible, your insurance will pay a set percentage of the bill. You may have to fill out forms and send them to your insurer to get reimbursed (paid back) for medical costs you have already paid. Sometimes the doctor’s office will do this for you, and then send you a bill for whatever your insurance didn’t cover. You also need to keep receipts for drugs and other medical costs. You are responsible for keeping track of your own medical expenses.
Health Maintenance Organizations (HMO)
The HMO will usually cover most expenses after a minimal co-payment. HMOs may limit your choice of providers to those within their approved provider network.
Point-of-Service Plans (POS)
A point of-service plan is a type of HMO. The primary care doctors in a POS plan usually make referrals to other doctors in the plan.
If your doctor refers you to a doctor out of the network, the plan will still pay all or most of the bill. But if you choose a doctor outside the network and the service is covered by the plan, you will have to pay co-insurance. Co-insurance is the amount you must pay in addition to what the insurance company will pay. It is usually a certain percent of the cost, for example the insurance company may pay 80% of the bill and you have to pay the other 20%.
Preferred Provider Organization (PPO)
The preferred provider organization is a combination of traditional fee-for-service and an HMO. Like an HMO, there are only a certain number of doctors and hospitals you can use. When you use those doctors (sometimes called “preferred” providers, other times called “network” providers), most of your medical bills are covered. When you don’t use these providers, the PPO makes you pay more of the bill out of your own pocket.
Other things to know about health insurance
Catastrophic illness clauses
There are many expenses associated with the management of most cancers. Some insurance plans provide for additional coverage under a “catastrophic illness” clause. These are policies that cover major medical care needs. The policies usually have a very high deductible and fairly low premiums. They are useful when a person’s primary medical policy has a lifetime limit and are appealing to people with chronic illnesses. Check to see if your plan contains such coverage.
Pre-existing condition exclusions
If you are a cancer patient and join a new health insurance plan, you may face a “pre-existing condition exclusion period.” A pre-existing condition is a health problem that you had before you joined your medical plan. With a pre-existing condition exclusion period, your plan will make you wait before they pay the costs of the pre-existing medical problem. The wait may be as long as a year for insurance you get through an employer.
There are certain employer-based insurance situations in which Federal law prevents the employer from imposing an exclusion period for a pre-existing condition. You may be exempt from this exclusion period if you have had health insurance with a previous employer and have not been without health insurance coverage for more than 63 days. Some states require an employer-based insurance company to cover your pre-existing condition even if you were without insurance for a bit more than 63 days. You can call the US Department of Labor at 1-866-444-EBSA to find out more about your specific situation.
However, if you are purchasing a plan that is not group coverage (including high risk pools), the pre-existing condition exclusion period is set by the state and can be many years or even unlimited. If you are getting a plan through someone other than an employer, the insurance provider can also impose an elimination rider that would keep that disease, body part, or body system from ever being covered by that policy.
Case managers and financial assistance planners
Hospitals, clinics, and doctors’ offices usually have someone who can help you fill out claims for insurance coverage or reimbursement. A case manager or a financial assistance planner may be able to help guide you through what can often be a complicated process.
Look carefully at heatlh insurance options
Look closely and compare plans if you are trying to decide among several insurance or managed care options. Sometimes there is an opportunity to look at and consider different types of coverage during open enrollment periods (the time periods when you are able to make changes in your coverage, usually once a year).
Hospital indemnity policies
There are some health insurance policies that pay a fixed amount for each day a person is hospitalized. There is usually a limit on the total number of hospital inpatient days that are covered in a calendar year. The money received from this type of policy can be used as the insured wishes, and it is often used for the other expenses that families face when one member is ill.
How to manage your health insurance
Do not allow your health insurance to expire. Pay premiums in full and on time. It is often difficult and expensive to get new insurance.
- Become familiar with your individual insurance plan and its coverage. Get a copy of your plan’s summary description (SPD), which tells you how the plan works, what benefits it provides, and how the benefits may be obtained or the process for filing your claim. If you think you might need more insurance, ask your insurance carrier whether it is available.
- Submit claims for all medical expenses even when you are not sure if they are covered.
- Keep accurate and complete records of claims submitted, pending, and paid.
- Keep copies of all paperwork related to your claims, such as letters of medical necessity, explanations of benefits, bills, receipts, requests for sick leave, and correspondence with insurance companies.
- Get a caseworker, a hospital financial counselor, or a social worker to help you if your finances are limited. Often, companies or hospitals can work with you to make acceptable payment arrangements if you let them know about your situation.
- Submit your bills as you receive them. If you become overwhelmed with bills, get help. Contact local support organizations, such as your American Cancer Society or your state’s government agencies, for extra help.
How to get answers to insurance-related questions
Questions about insurance coverage often come up during treatment. Here are some suggestions for dealing with insurance related questions:
- Speak with the insurer or managed care provider’s customer service department.
- Ask the cancer care team social worker for help.
- Talk with a hospital financial counselor.
- Talk with the consumer advocacy office of the government agency that oversees your insurance plan.
- Learn about the laws regarding insurance that protect the public. The Agency for Healthcare Research and Quality has a section entitled “Questions and Answers About Health Insurance” that may give you helpful information as a health care consumer. You can find this at www.ahrq.gov/consumer/insuranceqa/.
Keeping records of insurance and medical care costs
It can easily become overwhelming to keep track of the bills, letters, claim forms, and other papers that begin flowing into a household after a cancer diagnosis. Keeping accurate records of medical bills, insurance claims, and payments will help families manage their money better and keep their stress levels lower. Some families already have a system for handling their finances and records and only need to expand their system and create new files. Others may have to develop plans for handling the volume of paperwork. Record-keeping is also important for those who wish to take advantage of the deductions available in filing itemized tax returns. The Internal Revenue Service can give you information and free publications regarding tax exemptions for cancer treatment expenses.
Keep records of the following:
- medical bills from all health care providers
- claims filed
- reimbursements (payments from insurance companies) received and explanations of benefits (EOBs)
- dates, names, and outcomes of contacts made with insurers and others
- non-reimbursed or outstanding medical and related costs
- meals and lodging expenses
- travel (including gas and parking)
- long-distance telephone calls related to medical or other types of care, including psychosocial care
- admissions, clinic visits, lab work, diagnostic tests, procedures, treatments
- drugs given and prescriptions filled
Here are some helpful suggestions for record-keeping:
- Decide who will be the family record-keeper or how the task will be shared.
- Get the help of a relative or friend, if needed. This may be especially important for people who are single.
- Set up a file system in a file cabinet, drawer, box, or loose-leaf notebooks.
- Check all bills and explanations of benefits paid for to be sure they are correct.
- Review bills soon after receiving them.
- Pay bills by check if possible so that you will have a record of payment.
- Save and file all bills, payment receipts, and canceled checks (if copies of canceled checks are not possible, talk to your bank or credit union about how to get copies of canceled checks if needed.)
- Keep a daily log of events and expenses; a calendar with space for writing is useful.
- Maintain a list of cancer care team members and all other contact persons with their phone and fax numbers.
- Find out what is tax deductible.
When you have problems paying a medical bill
Many people go through times when they find it hard to pay their bills on time. Most hospitals and agencies are willing to discuss and help resolve these problems. To keep a good credit rating, it is important to pay attention to notices that state that a bill will soon be turned over to a collection agency. Families can do the following:
- Explain the problem to the hospital or clinic financial counselor or doctor’s office secretary.
- Work out a payment delay or an extended payment plan.
- Talk with the team social worker about sources of short-term help.
- Consider letting relatives or friends help out with money on a short-term basis.
Handling a claim denial or refusal to cover a prescribed service
It is not unusual for some claims to be denied or for insurers to say they will not cover a test, procedure, or service that doctors order. If this happens it is important to have a working relationship with a customer service representative or case manager with whom you can talk about the situation. A first step should be to re-submit the claim with a copy of the denial letter. You may need to have the doctor explain or justify what has been done or is being requested. Sometimes the test or service only will need to be “coded” differently. If questioning or challenging the denial in these ways is not successful, then you may need to:
- Put off payment until the matter is resolved.
- Re-submit the claim a third time and request a review.
- Ask to speak with a supervisor who may have authority to reverse a decision.
- Formally appeal the denial in writing, explaining why you think the claim should be paid. Your health care team members may be able to help with this.
- Request a written response.
- Keep the originals of all letters in your possession; the team may be able to help you make copies if necessary.
- Keep a record of dates, names, and conversations you have about the denial.
- Get help from the consumer services division of your state insurance department or commission.
- Do not back down when trying to resolve the matter.
- Consider legal action.
- cancer.org -
(To be continued)