Insurance Coverage

Health insurance helps pay for costly medical treatment and can protect you and your family from financial hardship. Some people have private health insurance coverage either through an employer (often called a group plan) or through an individual policy they've purchased. Even if you have coverage, however, certain treatments and charges may not be covered or paid in full. And there's the potentially overwhelming task of filing or appealing health insurance claims, especially when you're undergoing cancer treatment.

Understanding Your Coverage

Read your policy carefully to understand which services are covered and the portion of medical expenses you'll be responsible for paying. Your expenses may include: 

  • Premiums: the cost to have the health insurance plan. Premium payments are usually made monthly.
  • Deductibles: a fixed amount of money that you must first pay out of your own pocket each year, before the insurance plan will start to pay for your medical expenses.
  • Co-payments/Co-pays: a fixed amount that you must pay at the time you receive medical care or prescription drugs. Co-pay amounts aren't applied to the insurance plan deductible amount(s). Co-pay amounts may vary depending on whether you're seeing a specialist (such as a hematologist-oncologist) or a primary care provider, or if you are taking a brand name drug rather than a generic drug.
  • Co-insurance/Cost share: the percentage of medical expenses shared by you and the health plan. This is also referred to as a "cost share."  For example, if you have an 80/20 plan, the insurance plan pays 80 percent of your covered medical expenses and you would be responsible for the remaining 20 percent of your medical expenses. The co-insurance amount is in addition to any deductibles and co-payments.
  • Out-of-Pocket Expenses. The total amount of medical expenses that the patient is responsible for paying.
  • Out-of-Pocket Expenses Maximum. The limit on the total amount a health insurance company requires a patient to pay in deductible and co-insurance per year. After reaching an out-of-pocket maximum, the patient no longer pays co-insurance because the plan begins to pay 100 percent of covered medical expenses. Members are still responsible for services that are not covered by the plan. They must also continue to pay their monthly premiums.
  • In-Network Provider. An in-network provider is contracted with an individual’s health insurance company to provide services to plan members at a predetermined rate. The amount paid for an in-network provider is usually much less than the amount that you would pay for an out-of-network provider.
  • Out-of-Network Provider. An out-of-network provider is not directly contracted with an individual’s health insurance plan.
  • Lifetime and Annual Maximums or “Caps.” The maximum benefits that will be paid for each individual enrolled in the plan during each year or during the individual’s lifetime.
    • Under the The Patient Protection and Affordable Care Act, (ACA), for plan years that began either on or after September 23, 2010, plans can no longer impose lifetime caps, and as of January 1, 2014, plans cannot impose annual limits on essential health benefits.

 Use these worksheets to help you stay organized: Click Here

No Surprises Act. The No Surprises Act (NSA), effective January 1, 2022, establishes federal protections to help protect consumers from surprise medical bills. In the past, surprise medical bills often arose when patients with insurance unknowingly receive care from out-of-network providers. This most often happens during medical emergencies when patients may not be able to choose providers. This can also happen when an in-network provider works with an out-of-network provider, for example, if an in-network surgeon uses an out-of-network anesthesiologist. You can read one family's story here. 

Surprise billing is now banned thanks to the NSA. Instead of billing patients for outstanding costs, the provider and the insurer must negotiate payment. If they can’t reach an agreement, they’ll go to arbitration. Patients are not involved in the process. NSA does not apply to Medicare and Medicaid patients as these programs already provide protections. Visit Triage Cancer for more information and to learn what to do if you receive a surprise medical bill.

Types of Plans

The following general descriptions may vary from your coverage, so always check your own plan description.

  • Health Maintenance Organizations
    Health maintenance organizations (HMOs) provide plan members with lower costs and coordinated care from a specific list of health care providers, hospitals, and pharmacies. You must use these specific providers in order for your medical care to be covered by the plan. Plan members choose a primary care provider (PCP) and must get a referral from the PCP to see a specialist. Patients receiving emergency care may be required to notify their HMO within 24 hours of service. 
  • Preferred Provider Organizations
    Preferred provider organizations (PPOs) provide plan members with additional choices in providers, hospitals, and other healthcare professionals at a reduced fee. Members pay a standard co-payment amount of an office visit. Members can choose between either an in-network or an out-of-network provider, instead of being restricted to designated providers. A member may go to a specialist without needing a referral from a PCP. An in-network specialist is usually the least expensive choice. A member who sees an out-of-network specialist may have to pay the entire bill to the doctor, and then submit a claim for reimbursement. Patients who go to an out-of-network doctor may have to pay a separate deductible or pay the difference between the fee charged by the in-network doctor and the fee charged by the out-of-network doctor (“balance billing”). Members may need to get precertification (or preauthorization) for some types of care. Some types of services may not be covered.
  • Point-of-Service Plans
    Point-of-service (POS) plans blend the features of HMO and PPO plans. Plan members can choose the type of provider that best suited to their needs each time they seek care. Plan participants can designate an in-network provider to be their PCP. Members usually see their chosen PCP first for any medical issues. If necessary the member is referred to a specialist. A POS plan member may need a referral to see a specialist. Members may visit a licensed provider outside the network and still receive coverage, although this would usually cost more. 
  • Exclusive Provider Organizations
    Exclusive Provider Organizations (EPOs) are similar to PPO plans in that they provide plan members with reduced costs and members pay a co-pay amount for an office visit. However, members must select providers from a limited list. A plan member consulting an out-of-network doctor may incur from 20-100 percent of the costs. This plan may be difficult for patients who require a number of unique specialists. 
  • Fee-for-Service
    Fee-for-Service (FFS) plans are more flexible than other plans, but involve higher premiums and higher out-of-pocket expenses. They also require more paperwork. Members can choose their own providers. Members can visit a specialist without a referral form a PCP. Members may have to pay the provider directly for medical services and then submit a claim for reimbursement. Members receive limited coverage for routine care.

Source: Cancer and Your Finances. Reviewed by Monica Fawzy Bryant, Esq.

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