Facing a cancer diagnosis brings many challenges, and navigating health insurance is a critical one. Understanding your health insurance options is vital, not just for your finances, but also for your overall well-being as you manage diagnosis, treatment, and lifestyle adjustments. With open enrollment periods approaching, it’s crucial to make informed decisions about your healthcare coverage.
This article will clarify confusing health insurance terms and explore your options after a cancer diagnosis, ensuring you can access the care you need without unnecessary financial stress.
If you are seeking expert guidance on your cancer diagnosis and treatment plan, please call us or chat online to connect with our dedicated team.
Decoding Health Insurance Terms
To confidently choose and utilize your health insurance, understanding key terms is essential. Here are some common terms you should know:
Deductible: This is the amount you pay out-of-pocket before your health insurance starts covering costs. For example, a $1,000 deductible means you pay the first $1,000 of healthcare expenses before your insurance kicks in.
Premium: This is your regular payment for health insurance coverage, typically paid monthly. Think of it as the subscription fee to have insurance.
High Deductible Health Plan (HDHP): These plans have higher deductibles, meaning you pay more out-of-pocket initially. In 2023, a plan with a deductible of $1,600 or more for individuals and $3,200 for families is considered an HDHP by the government. HDHPs often have lower monthly premiums, which can be attractive if you don’t anticipate needing much healthcare.
If you have an HDHP, you might qualify for a Health Savings Account (HSA). HSAs offer tax advantages and can help you save and pay for healthcare expenses.
Out-of-Pocket Maximum: This is the absolute limit on how much you’ll pay in a year for deductibles, co-pays, and co-insurance. Once you reach this maximum, your health insurance covers 100% of eligible costs for the rest of the plan year. Knowing this number helps with financial planning. However, remember that out-of-network costs or services not covered by your plan may not count towards this maximum.
Co-pay: This is a fixed amount you pay for specific services, like a doctor’s visit or prescription. Co-pays vary depending on the service type and count towards your out-of-pocket maximum. Review your plan’s co-pays, as they can accumulate quickly.
Co-insurance: After meeting your deductible, co-insurance is the percentage of costs you share with your insurance company. For instance, you might pay 20% while your insurance pays 80%. Co-insurance payments also contribute to your out-of-pocket maximum.
In-network vs. Out-of-network: Insurance companies have networks of doctors and hospitals they contract with. In-network providers are typically cheaper. Out-of-network providers may be partially covered or not covered at all, leading to higher costs. Always check if your preferred doctors are in-network for a plan you’re considering.
Cancer Insurance: This is a supplemental policy designed to cover costs that your primary health insurance might not, such as out-of-pocket expenses and non-medical costs like childcare or lost income due to cancer. However, if you already have a cancer diagnosis, you are generally ineligible for new cancer insurance policies. Carefully evaluate these policies to ensure they genuinely enhance your coverage instead of adding limitations. Catastrophic illness insurance is a related option that can be added to existing health or life insurance to help manage the high costs of serious illnesses like cancer.
Exploring Types of Health Insurance
Health insurance plans vary widely and are available through government programs and private insurers. Here are common types to consider:
Government-Funded Plans:
Medicare
Medicare is the federal health insurance program primarily for people 65 and older, and certain younger individuals with disabilities or End-Stage Renal Disease. Medicare offers various coverage options, including Medicare Advantage plans, which provide additional benefits beyond basic Medicare. Learn more about Medicare coverage.
Medicaid
Medicaid is a joint federal and state program providing health coverage to eligible low-income individuals and families, seniors, and people with disabilities. Medicaid is administered by each state, so eligibility rules and benefits vary. Find details about Medicaid programs.
Tricare
Tricare provides healthcare for active-duty and retired U.S. military personnel and their families, National Guard and Reserve members, survivors, and certain former spouses. Care can be received through military facilities or civilian providers. Veterans should visit the U.S. Department of Veterans Affairs website for information on VA healthcare benefits.
Private Health Insurance Plans:
Private health insurance is offered by commercial insurance companies and regulated by state and federal laws. These plans can be obtained through employers or purchased individually. Check with your employer’s HR department or professional organizations for group plan options.
Private plans include various structures, such as:
-
Health Maintenance Organizations (HMOs): HMOs typically require you to choose a primary care physician within their network and often need referrals to see specialists. They usually offer lower out-of-pocket costs but less flexibility in provider choice.
-
Preferred Provider Organizations (PPOs): PPOs offer more flexibility than HMOs, allowing you to see doctors both in and out of network (though out-of-network care is more expensive) and usually without needing referrals.
-
Fee-for-service: These plans pay providers directly for services or reimburse you. They offer the most provider choice but can be more expensive and require more paperwork for reimbursements.
If you have employer-sponsored insurance and need to stop working or reduce hours due to cancer, you may be eligible for COBRA (Consolidated Omnibus Budget Reconciliation Act), which allows you to continue your employer-sponsored health coverage for up to 18 months (you typically pay the full premium). Learn more about COBRA.
Obamacare (Affordable Care Act – ACA) Marketplace
The Health Insurance Marketplace, established by the Affordable Care Act (ACA), offers subsidized private health insurance plans to individuals and families who don’t qualify for programs like Medicare or Medicaid. The ACA ensures that you cannot be denied coverage or charged more due to pre-existing conditions like cancer. When selecting a Marketplace plan, aim for one that provides good coverage both in and out of network.
Key Questions When Choosing a Health Plan After a Cancer Diagnosis
Thanks to the Affordable Care Act, you absolutely can get health insurance even after a cancer diagnosis. Insurers cannot deny coverage or charge you more because of this pre-existing condition. However, understanding plan variations is vital to choose the best option.
As you explore health insurance plans, ask yourself these crucial questions:
- What type of cancer treatment will you likely need? (Surgery, chemotherapy, radiation, etc.)
- How long is your treatment expected to last? (Months, years?)
- Where will you receive treatment? (Specific hospital or cancer center?)
- What is your current health insurance situation? (Do you have employer insurance, are you uninsured, etc.?)
Your answers, along with your financial situation, will guide your decision on:
- High deductible plan vs. lower deductible plan: Can you afford higher out-of-pocket costs initially for potentially lower premiums?
- In-network coverage: Is your preferred treatment center and doctors in-network for the plan?
- Health Savings Account (HSA), Health Reimbursement Arrangement (HRA), or Flexible Spending Account (FSA): Are these options available to help with costs?
- Supplemental insurance: Would cancer or catastrophic illness insurance be beneficial (if you are eligible)?
For a comprehensive overview of cancer-related coverage and costs, consult the American Society of Clinical Oncology’s cancer.net page.
Cancer Treatment Coverage: What to Verify
When evaluating plans, focus on out-of-pocket costs (premiums, co-pays, deductibles, maximums). Also, confirm:
- Provider network: Are your oncologists and treatment facilities in-network?
- Specific cancer treatment coverage: What is covered for surgery, radiation, chemotherapy, immunotherapy, targeted therapy, etc.?
- Medical supplies coverage: Are supplies like gloves, needles, wheelchairs, nutritional supplements covered?
- Coverage for prostheses, wigs, mastectomy bras: Are these covered if needed?
Review the plan’s formulary (list of covered drugs) and check if pre-authorization (prior approval) is required for specific medications, tests, or procedures.
Inquire about coverage for supportive care services that are often crucial for cancer patients:
- Home health visits
- Palliative care
- Physical therapy and rehabilitation
- Mental health counseling
Cancer Screening Coverage
Confirm if the plan covers routine cancer screenings and preventive tests, including genetic testing, and understand the difference between routine and diagnostic testing coverage. The plan’s “summary of benefits” document should detail this information. Many insurers cover routine screenings like colonoscopies and mammograms, following recommended guidelines.
Health Savings Accounts: A Smart Tool
HSAs, HRAs, and FSAs are tax-advantaged accounts, often through employers, that allow you to set aside pre-tax money for healthcare expenses. Contribution limits apply, and rules vary on fund rollover. If you anticipate ongoing healthcare costs, maximizing contributions to these accounts can significantly reduce your financial burden. Check with your employer about available accounts and contribution options.
Short-Term Disability and Cancer
If cancer treatment impacts your ability to work, you may be eligible for Social Security Disability Insurance (SSDI) from the U.S. government. SSDI provides income to individuals who have worked and paid Social Security taxes and are now unable to work due to disability, including certain cancers. The Social Security website lists cancers considered “disabling.” Learn more about SSDI for cancer patients.
Additional Financial Support Options
Beyond health insurance, other resources can help manage cancer-related expenses:
-
Medical expense tax deductions: You may deduct certain unreimbursed medical expenses on your federal income taxes, including:
- Mileage to medical appointments
- Prescription drug costs
- Meals during extended medical visits
Consult a tax advisor for details.
-
Non-profit and volunteer organizations: Local and national organizations offer financial aid for serious illnesses, covering co-pays, co-insurance, premiums, deductibles, and other out-of-pocket costs.
-
Hospital and cancer center financial assistance programs: Many institutions offer programs to help patients with financial needs.
-
Pharmaceutical patient assistance programs: Drug companies often provide programs to assist eligible patients with medication costs and related expenses.
Contact your local American Cancer Society chapter or United Way for resources in your area.
If you are seeking a second opinion on your cancer diagnosis or treatment plan, please call us or chat online to connect with our expert team.
