Understanding Insurance


Financial Health
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Insurance is a critical piece to getting medical, dental, and vision tests and scans. Your insurance plan, also called a benefits plan, will dictate whether you will need prior authorization; what types of exams are covered; and how frequently you may have them. The formulary dictates what drugs are covered and what you owe for the drugs, excluding your copay and coinsurance.

Insurance Options

You typically have options when it comes to insurance. Employer-sponsored means your employer offers you and/or your spouse and dependents a benefits package as a part of your compensation.

Oftentimes these plans are offered by commercial insurance companies, such as BlueCross, Aetna, UnitedHealthcare, Kaiser, etc. During your employer’s open enrollment, they will explain the plans available for you to choose from. Ask when your benefits will begin. You don’t have to enroll in your employer’s plan, but, sometimes your employer is willing to pay a portion of your premium, which reduces your health care costs.

If employer-sponsored benefits are not an option for you, you can check the Healthcare Marketplace, which was made possible by the Affordable Care Act. Open enrollment for the Marketplace is November 1 through December 15, and coverage begins January 1. Based on your age and income, you may also qualify for Medicare or Medicaid plans, both federally and within your state.

Choosing a Plan

Typically, you choose health insurance plans during open enrollment, unless you qualify for a special enrollment due to a qualifying life event. These qualifying events include losing your benefits, marriage/divorce, having a baby or adopting, or if your household income shifts. When shopping for a benefits plan, here are a few things you want to look into:

  • In-network coverage: The benefits company will have a list of in-network providers and health care systems. Check to see if your medical team and preferred hospitals are included.
  • Continuity of care: You may be able to continue to see your current doctor or therapist for a specified period if you must switch plans. This can be crucial if your scans overlap when you have to change your plans or doctors.
  • Additional services: Check for coverage for services like physical therapy, mental health and holistic care. If you need medical supplies, like ostomy supplies, ask about your limits and expected costs.
  • Premiums/deductibles/out-of-pocket (OOP) maximums: How do the figures on your available plans align with your anticipated medical expenses and what can you afford? If you’re anticipating surgery, treatments, colonoscopy, and/or imaging in the future, you may want a benefits plan with a lower deductible or out-of-pocket maximum, even if the premium is higher. If your follow-up care has slowed down, you may consider a higher deductible or out-of-pocket maximum and lower premium.

While cancer teaches us to expect the unexpected, choose your benefits package based on the information you have now and the security you need for the future.

One way to calculate is take the annual premium and add the OOP max, and pick the lowest option because that’s the max you’ll pay for the year.

Basic Insurance Terms to Know

Premium: The cost of your insurance policy.

Deductible: What you must pay before your insurance benefits cover costs.

Out-of-Pocket Maximum: The most you’ll pay for covered services in a calendar year. Many survivors hit their out-of-pocket maximums each year.

Copay: What you pay right away when you check in at the doctor’s office or pick up a prescription. This is determined by your insurance plan.

Claim: Paperwork submitted to your insurance company each time you use your benefits. Typically your doctor’s office or medical facility will submit the claim on your behalf.

Explanation of Benefits: Sent by your insurance company telling you what was billed to your insurance; what insurance paid; and the estimate of what you’ll owe. This is NOT a bill.

In-Network: Doctors and facilities that have a contract with your insurance company; typically your costs are lower since insurance will cover more of their fees.

Out-of-Network: Doctors and facilities that do not have a contract with your insurance company. You can submit the claims to your insurance company, but you will likely owe more, since insurance won’t cover as much of the cost. You will owe 100% of the cost the doctor or facility charges for services.

Lifetime Maximum: The maximum amount your insurance plan will pay during your lifetime.

Pre-existing Condition: A health condition you had and knew about before you enrolled in your medical plan.

Appeal: If your insurer denies your claim or refuses to cover a procedure/scan/test your doctor orders, read the denial letter carefully for the reason. You can work with your doctor to follow an appeals process and request that the insurance company reconsider.

Getting Insurance Help

Insurance can be overwhelming. If you are not sure how to navigate it, there are (free) insurance brokers that can help you to select the right plan if you tell them what is most important to you in your coverage.

Our partners at Triage Cancer offer free, 1-on-1 insurance help for cancer patients and their families through their Legal & Financial Navigation Program.

And if you’re stuck, reach out to our community for help and resources. We’re here for you.

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