Navigating Insurance

Your insurance plan, also called a benefits plan, will dictate whether you will need prior authorization (insurance approval before the procedure or test); 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

Employer-sponsored options

This 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 Blue Cross, 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.

Healthcare Marketplace

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.

Medicare or Medicaid

Based on your age and income, you may also qualify for Medicare or Medicaid plans. Medicare is a federal program that may be an option for you if you are age 65 or older and you (or your current or former spouse) paid Medicare taxes.

Medicaid is a joint federal and state program for children, pregnant women, parents, seniors, and individuals with disabilities. Federal law requires states to cover certain groups of individuals like low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI). States may also offer coverage for other groups. The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age 65.

Enrollment

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
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 quantity limits and expected costs.
Premiums/deductibles/out-of-pocket 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.

Insurance Terms

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 why. You can work with your doctor to follow an appeals process and request that the insurance company reconsider.

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.

Coinsurance

Your health insurance covers a service after you have paid your deductible, but you’re still responsible for a percentage. For example, you pay 25% of a bill in coinsurance, and your insurance pays 75% of the bill.

Copay/Copayment

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.

Deductible

What you must pay before your insurance benefits cover costs.

Explanation of Benefits (EOB)

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.

Lifetime Maximum

The maximum amount your insurance plan will pay during your lifetime.

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.

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.

Pre-existing Condition

A health condition you had and knew about before you enrolled in your medical plan.

Premium

The cost of your insurance policy.

Getting Help

Insurance can be overwhelming. If you are not sure how to navigate it, there are (free) insurance brokers that can help you select the right plan if you tell them what is most important to you in your coverage. And if you’re stuck, reach out to our community for help and resources.

For help with cancer and insurance coverage specifically, visit Triage Cancer. They offer informational resources and support to help you manage your health insurance and finances while dealing with a cancer diagnosis.

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