Understanding Health Insurance for Cancer Treatment
The world of medical insurance is a confusing one, so much so that 56% of Americans admit to feeling “completely lost when it comes to understanding health insurance³.”
To provide some direction, we walk you through the basics below.
What Is Medical Insurance and How Does It Work?
Medical insurance, or health insurance, is a contract that requires an insurance company to pay some or all of a person’s healthcare costs. In exchange for this coverage, the insuree pays a monthly fee called a premium.
Most insurance policies require you to pay a flat fee for doctor’s visits and other services (called a co-pay). Or, you may be expected to pay a percentage of the cost (called co-insurance).
Your medical expenses will also be impacted by the policy’s deductible, which is the amount you pay for covered healthcare services before your insurance plan begins to pay.
Additionally, all medical insurance policies must set an out-of-pocket maximum. This is the most you’ll have to pay for covered services in a plan year.
In-Network vs. Out-of-Network: What’s the Difference?
Another important distinction is in-network vs. out-of-network.
In-network health care providers contract with your insurance company to accept discounted rates. This lowers the amount you pay out-of-pocket.
For example, a doctor may typically charge $200 for a service. However, Aetna – a top health insurer – may negotiate a discounted rate of $150.
Comparatively, out-of-network providers have not agreed to these discounted rates. Thus, you can expect to pay more out-of-pocket.
If you want to know if a doctor is in-network, call your insurance company. Some companies even have provider lookup tools on their websites.
What Is Prior Authorization?
Health insurance companies often mandate pre-approval, also called prior authorization.
Prior authorization involves verifying that a procedure or service is medically necessary before it’s provided. Pre-approval can also apply to prescription drugs and out-of-network services.
Premium: The amount you pay for medical insurance every month
Co-Pay: A fixed amount ($25, for example) you pay for covered health care services after you’ve paid your deductible
Co-Insurance: A percentage (20%, for example) of costs of a covered health care service you pay after you’ve paid your deductible
Deductible: The amount you pay ($2,000, for example) for covered health care services before your insurance plan begins to pay
Out-of-Pocket Maximum: A cap or limit on the amount of money you have to pay for covered health care services in a plan year
In-Network: A doctor or provider who contracts with your health insurance company and has agreed to accept a discounted rate
Out-of-Network: A doctor or provider who doesn’t contract with your health insurance company and hasn’t agreed to accept a discounted rate
Prior Authorization: A process in which medical providers obtain approval from a health insurance company before providing a service
How Much Does Medical Insurance for Cancer Treatment Cost?
Your monthly health insurance premium will depend on various factors, including:
The type of health insurance plan you choose
Your age and location
Whether you qualify for government subsidies
How many adults and children are covered by your plan
Average Health Insurance Premiums by Family Size:⁴
Individual (40-year-old): $477
Couple (two 40-year-olds): $954
Couple with a kid (age 0-14): $1,230
Couple with two kids (ages 0-14): $1,506
Couple with three kids (ages 0-14): $1,782
How To Get Medical Insurance for Cancer Treatment
If you’re currently uninsured, there are many different ways you can secure health insurance coverage. The most common options include:
Enrolling in job-based health insurance
Joining your spouse’s health insurance plan
Purchasing health insurance through your university
Using the government’s Health Insurance Marketplace
Exploring government health insurance programs
Option 1: Enrolling in Job-Based Health Insurance
Many companies offer health insurance as an employee benefit. You can enroll in these benefits when you’re first hired or later during an annual open enrollment period.
Qualifying events like getting married, having a child, or transitioning from part-time to full-time can also trigger a special enrollment opportunity.
Option 2: Joining Your Spouse’s Health Insurance Plan
If your spouse receives employer-sponsored health insurance, you may be eligible to join their plan.
However, it’s important to remember that adding people to a health insurance plan will raise your monthly premium.
Option 3: Purchasing Health Insurance Through Your University
If you’re an undergraduate or graduate college student, you may be eligible to purchase health insurance through your institution.
It’s also worth noting that, in most cases, you can get added to or stay on your parent’s health plan until you turn 26 years old.
Option 4: Using the Government’s Health Insurance Marketplace
Many Americans choose to purchase health plans through the Health Insurance Marketplace.
This government resource allows people to compare insurance plans for coverage and affordability.
Even better, the government offers subsidies when you buy health insurance through the marketplace.
Option 5: Exploring Government Health Insurance Programs
Medicaid is a joint federal and state program that provides health coverage. Eligibility is determined by income among other factors.
Comparatively, Medicare is a government-subsidized health insurance plan designed for people 65 or older.
Common Types of Health Insurance Plans
There are many different types of medical insurance for cancer treatment, including:
Health Maintenance Organizations (HMOs)
An HMO is a budget-friendly plan that provides access to a network of participating health care professionals and facilities.
If you purchase an HMO plan, you’ll be required to choose a primary care provider (PCP) from your network. This PCP will coordinate all of your care. They will also be required to provide referrals so that you can see in-network specialists.
Exclusive Provider Organizations (EPOs)
Like HMOs, EPOs only cover in-network care. However, these plans offer larger networks. Additionally, most plans don’t require a PCP nor do they require referrals to see specialists.
Preferred Provider Organizations (PPOs)
PPOs offer the most flexibility. You can see specialists and out-of-network doctors without a referral. Plus, co-pays for in-network doctors are relatively low. However, in exchange for these benefits, you’ll pay a high monthly premium.
Point-Of-Services (POS) Plans
POS plans combine features of HMO and PPO plans. Like an HMO, you must select an in-network PCP to coordinate your care and provide referrals. However, like a PPO, you can see out-of-network doctors.
Deductibles and co-pays
Referrals to see specialists
Recommended, but not required
Recommended, but not required
Additional Types of Health Insurance
High-Deductible Health Plans (HDHPs): A health insurance plan with a high deductible but low monthly premiums. Sometimes referred to as a “catastrophic plan.”
Health Savings Accounts (HSAs): A type of savings account that lets you set aside pre-tax income to use for qualifying medical services.
Flexible Savings Accounts (FSAs): Similar to an HSA, except it’s owned by your employer.
What Is Cancer Insurance?
Cancer insurance is designed to help you handle the unexpected medical and non-medical expenses of cancer. It’s a type of supplemental insurance, meaning it’s an add-on to your regular medical insurance coverage.
Typically, these policies pay a lump sum ranging from $5,000 to $200,000 when you receive a cancer diagnosis. You can use this money to pay for anything, from prescription drugs to rent.
The catch? Getting cancer insurance after a diagnosis is very unlikely. Many companies will also deny coverage if you have a personal history of cancer.
How Much Does Cancer Insurance Cost?
Cancer insurance policy rates depend on various factors, including:
However, the average rates range from $20 to $90 per month.
Other Types of Supplemental Insurance Policies
In addition to cancer insurance, there are many other supplemental insurance policies you can purchase.
Critical Illness Insurance: Provides a lump sum if and when a policyholder is diagnosed with a critical condition.
Long-Term Care Insurance: Reimburses policyholders for services that assist them with activities of daily living (e.g. eating, bathing, dressing) in the event of sickness or injury.
Disability Insurance: Replaces a portion of a policyholder’s income in the event of sickness or injury.
Questions To Ask Before Selecting Medical Insurance for Cancer Treatment
If you have recently been diagnosed with cancer, it’s imperative that you select an insurance plan that offers comprehensive coverage.
You can compare and contrast plans by asking the questions below. You can also download and print our cancer insurance checklist.
Is my PCP in-network?
Are referrals required for specialists?
Is pre-authorization required for certain medical services?
Are my specialists (e.g. rheumatologists, oncologists, psychiatrists) in-network?
Is my hospital in-network?
Are other medical facilities (e.g. infusion centers, imaging centers) in-network?
Are my prescription drugs covered?
Is pre-authorization required before prescriptions can be filled?
Managing Your Health Insurance Plan During Cancer Treatment
Typically, your provider will bill the health insurance company for you and send you a bill for the remainder.
But, in some cases, you will be required to file a claim yourself. There also may come a time when you will need to appeal a denied claim.
What if I Need to File My Own Claim?
When a medical provider cannot bill a health insurance company on your behalf, you can submit a claim online or by mail.
These forms are often self-explanatory, asking for information like:
Your insurance policy number
Who received the services (e.g. yourself, your spouse, your child)
What the visit was for (many insurance companies want to see itemized receipts)
What if a Claim Is Denied?
It’s not unusual for health insurance companies to refuse to cover a test, procedure, or other services.
When this happens, you have three options:
Call Your Health Insurance Company: Sometimes, your insurer simply needs more information regarding the procedure and why it’s medically necessary.
Make a Formal Appeal: If this doesn’t work, you can formally appeal the denial in writing. You may even consider hiring a lawyer, depending on the cost of the procedure. Or, you can request an external review by people outside of your health insurance company.
Ask for a Bill Reduction: If you can’t resolve the issue directly with your health insurance company, contact your medical provider to see if the bill can be reduced. Many doctors are willing to offer a discount or set up a payment plan.
Know Your Rights: ACA and Medical Insurance for Cancer Treatment
In 2010, the Patient Protection and Affordable Care Act – otherwise known as the Affordable Care Act (ACA) – was signed into law.
This legislation provides specific protections for individuals with pre-existing conditions, including cancer.
More specifically, the ACA mandates that health plans:
Must cover essential health benefits such as cancer treatment and follow-up care
Must cover preventative services (e.g. mammograms, colonoscopies, and other cancer screenings)
Cannot deny coverage to people based on their medical history or increase rates based on pre-existing conditions
Cannot drop coverage when someone receives a cancer diagnosis
The ACA also places a cap on co-pays, co-insurance, and deductibles.
In 2022, the maximum allowable out-of-pocket limit for in-network covered services for an individual is $8,700.
Protections Provided by COBRA
Signed into law in 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers the right to continue group health benefits under certain circumstances.
These circumstances include, but aren’t limited to:
Voluntary or involuntary job loss
Reduction in work hours
The downside? Qualified individuals may be expected to pay the entire premium for coverage. This can make COBRA a very expensive health insurance option.
What Happens if You Get Cancer and Don’t Have Health Insurance?
Despite protections instated by the ACA, health insurance remains unaffordable for many people. Because of this, nearly 1 in 10 Americans don’t have medical coverage⁵.
Being uninsured may be an acceptable risk if you’re healthy. But what happens if you get cancer and don’t have health insurance?
In this situation, you will be charged 100% of the cost of treatment. That could mean forking over $10,000 per month for immunotherapy or $12,000 per month for chemotherapy⁶.
Financial Aid for Cancer Treatment
Fortunately, there are many different financial aid resources available for uninsured or underinsured oncology patients.
For example, nonprofit hospitals are required by law to make charity care available to needy patients.
Essential hospitals, also called safety-net hospitals, also provide health care for the uninsured.
Other sources of financial aid for cancer treatment include:
At SERO, we understand that navigating the costs of cancer can add significant stress to your cancer journey. At a time when you should be focused on recovery, you may be worried about how your family will afford cancer treatment alongside other recurring bills like rent, auto loans, and groceries.
To ease your burden, the compassionate and understanding providers with SERO accept a variety of health insurance plans. We also offer flexible payment options, including payment plans, so that you can pay for medical services at your own pace.
To learn more about financial assistance at SERO, call 704-333-7376 today.