it is important for cancer survivors – like everyone else – to have adequate and dependable health insurance. There are many kinds of policies on the market, though not all offer the same protection. It is best to have comprehensive health coverage that will pay for all of your basic health-care needs such as hospital and doctor care, lab tests, medical equipment, and prescription drugs. When evaluating a policy to see if it meets your needs, in addition to looking at the premium, you need to consider:
- What services are covered?
Look at the list of services the policy covers. Look also at what services are explicitly excluded from the policy. for example, many policies exclude coverage for care in clinical trials, drugs that are not on a formulary or approved list, and other important services. Many policies also temporarily exclude services related to a pre-existing condition. And some add “riders” that permanently exclude services relating to a specific condition, organ system, or body part. When considering a policy, it is important that you find out whether the services you may need during your cancer treatment are covered by the plan. If you are considering joining a managed care plan, you should also find out whether your current doctors belong to the plan’s network. Many cancer patients have developed a strong relationship with their doctors and may want to continue receiving treatment from them. remember, however, that just because your doctor is a member of a certain network today does not guarantee that he or she will remain in that network forever. Also, it is important for you to review the policy to find out what steps you will have to take in order to see a specialist.
- How much will I have to pay for covered services?
The amount of money you pay to purchase health insurance is called a premium. When
considering a health insurance policy, look also at the annual deductible (the amount you pay each year before coverage kicks in). Some policies also have separate deductibles for certain services, such as hospitalization or drugs. Look, too, at the copayment (a flat fee, such as $10 or $20, that you pay the provider at the time of service) and coinsurance (a percentage of the bill that you pay) that apply to covered services. Also, watch out for balance billing – something that happens when the plan limits its payment to the part of the fee that it considers reasonable, leaving you responsible for the rest. See if your policy requires doctors and hospitals to accept the plan’s payment as payment-in-full. Most policies have an out-of-pocket limit or “stop-loss” feature that caps the amount you have to pay in deductibles, coinsurance, or copayments. After that, the plan pays 100 percent. However, the out-of-pocket limit usually does not apply to balance billing. finally, policies often have a lifetime limit or lifetime maximum on covered benefits (such as $1 million). Some also impose annual limits on what they will pay.
- What type of policy is it and from whom can I get care?
fee-for-service, or indemnity policies, are what people think of as traditional insurance. Under these policies you choose your own doctor or hospital and the insurance company pays a portion of your bill after you meet your deductible. managed care policies, by contrast, usually require you to get care from their network of participating providers, including doctors, hospitals, and pharmacies. In addition, managed care plans often require their members to designate a primary care provider (pcp) or “gatekeeper” who must provide a referral for any visits to a specialist, even a specialist in the plan’s network. These types of plans are most commonly referred to as health maintenance organizations or Hmos. There are advantages and disadvantages to managed care plans. These include:
advantages
- Lower cost to you (premiums and out-of-pocket costs).
- No claims for you to file.
- Coverage for preventive and routine care.
disadvantages
- Limited choice of health professionals, pharmacies, and hospitals.
- Care from specialists may require a referral from your primary care provider (PCP).
- Limited or even no coverage for out of network care.
There are hybrid policies, sometimes called preferred provider organizations (ppos) or point-of-service options (pos), that offer more flexibility than traditional managed care plans by allowing you to have a choice of getting care from in- or out-of-network providers, often without pre-approval. You should be aware that you usually pay more – sometimes a great deal more, including balance billing – for care received out of network.