Maximizing Payment from your Insurance Plan

When you’re battling cancer, you want every penny of coverage you can wring from your health insurance, whether it’s private insurance or Medicare. Here are some tips to help you succeed.

Understand Your Benefits

If you have private health insurance, carefully review your policy so you know the rules and procedures to follow and what’s covered. If you have Medicare, review your “Medicare and You” document. Your insurer can clarify points you don’t understand.Some things to look for include:

  • How much will you have to pay (deductibles, copayments and coinsurance), and is there an out-of-pocket limit?
  • Does the plan require you to get care from certain providers or reimburse less for care provided by other providers?
  • Does the insurer have to approve your cancer treatment plan before you begin treatment?
  • Are second opinions covered? How about participation in a clinical trial?
  • Who should file insurance claims — you or your health care providers?
  • What is the appeal process if a claim is denied? You should expect some claims to be denied the first time they’re submitted, but the insurer may pay after you appeal.

If Possible, Work With One Person

Ask to be assigned to one person at your treatment facility — such as a financial counselor — who will help with financial issues. This person may:

  • answer questions about your medical bills;
  • estimate the cost of your cancer treatment and tell you if the cost might exceed any coverage limit in your health insurance, so you can plan for the extra expense;
  • help you with claims and with appeals; and
  • refer you to financial assistance organizations if you have difficulty paying expenses not covered by insurance (see Financial Help for Patients and Families).

You also can ask your insurer to assign one person, a case manager, to work with you on your claims.

Track Claims, Appeal Denials

Review statements of account from health-care providers, and ask about any charges that don’t look right.

If you must file claims yourself, do so immediately. Not sure if an expense is covered? File a claim and see what happens.

When you receive explanations of benefits (EOBs) from your insurer (or Medicare summary notices [MSNs] if you’re in Medicare), compare them to the provider’s statements of account to make sure all charges have been submitted for reimbursement. If your insurer has denied one of your claims, don’t accept the decision — appeal it.

If you have Medicare supplemental (“Medigap”) insurance, make sure Medicare knows about it. Check your MSNs to confirm that claims have been passed on to your Medigap insurer after Medicare has paid its part.

If you have a hospital indemnity policy, don’t forget to submit a claim if you’re hospitalized. The insurance payment comes directly to you.

If you think your insurer has treated you unfairly, find out which government agency oversees your plan, then lodge a complaint.

Look for Ways to Reduce Drug Costs

When your doctor prescribes a medication, ask about the availability of less expensive drugs, including generics, that would have the same effect. Try to get a drug that is on your insurer’s preferred drug list, since reimbursement will be higher.

If your insurance offers a mail-order prescription program, this option may be cheaper than a local pharmacy.

Some pharmacies and discount stores offer generic drugs at extremely low prices, such as $4 for a 30-day supply. While your cancer-related drugs probably won’t be offered in these programs, you might be able to save money on other drugs you use.

If you’re in Medicare and have signed up for a Medicare Part D prescription drug plan, you may want to research other Part D plans and change to another one if it covers more of your cancer-related prescriptions. You can switch plans from Nov. 15 through Dec. 31 of each year and under special circumstances.

If You’re Uninsured and Have Cancer

If you have cancer but don’t have health insurance, an independent insurance broker may be able to find insurance for you, or you might get coverage through a risk pool — a program to provide insurance for people with pre-existing medical conditions — if your state has one. If you’re a member of a professional or fraternal organization, you might be able to apply for “guaranteed issue” group insurance through the organization.

You may qualify for assistance from your state’s Medicaid program if your income is low and you meet certain other criteria. Apply even if you’re not sure you meet the criteria. A Medicaid caseworker will evaluate your situation and decide whether you qualify. If you get into Medicaid, you’ll get help from the federal Medicare program for your prescription drug costs.

Financial assistance organizations also may be able to help with your bills (see Financial Resources). Two organizations whose missions focus on financial assistance and support are:

Patient Advocate Foundation which provides mediation and arbitration services to patients to remove obstacles to health care, including medical debt crisis, insurance access issues and employment issues for patients with chronic, debilitating and life-threatening illnesses.

CancerCare whose programs include counseling and support groups, education, financial assistance and the CancerCare Co-Payment Assistance Foundation.

Additional Sources of Information