Handling Insurance Matters Related to Cancer

It is important to have and keep good medical insurance. Many patients have private insurance through employee group plans or individual plans. There are several types of health insurance plans, so it’s important for patients to become familiar with their individual insurance plans and their provisions to know what they will have to pay for themselves.

This information can be found in the Summary of Benefits and Coverage that can be obtained from the patient’s insurance administrator at work or from the company that sold the individual policy. As of 2014, individual policies can be purchased in each state’s insurance marketplace without regard to pre-existing conditions.

Keeping Records of Health Insurance and Medical Care

Another option to consider is supplemental insurance, which pays a fixed amount for each day a person is hospitalized. There is usually a limit on the total number of hospital inpatient days that are covered in a calendar year. Supplemental policies are often used to pay for medical expenses not covered by the insurance plan or other expenses that might come up during an illness, but are really only helpful if patients already have health insurance coverage to cover the bulk of their health care costs. The money received from this type of policy can be used however a policy holder wishes. It is often used for the other expenses that families face when one member is ill.Keeping accurate records of medical bills, insurance claims and payments will help families manage their resources and reduce stress. Record-keeping is also important for those who wish to take advantage of the deductions available in filing itemized tax returns. The Internal Revenue Service (irs.gov) can provide information and free publications regarding tax exemptions for cancer treatment expenses.

KEEP RECORDS OF THE FOLLOWING:

• Medical bills from all health care providers
• Claims filed
• Reimbursements and explanations of benefits
• Dates, names and outcomes of contacts made with insurers and others
• Non-reimbursed or outstanding medical costs and copayments
• Meals, lodging and travel expenses, including gas
• Cell phone or telephone expenses related to medical or other types of care, including psychosocial
• Admissions, clinic visits, lab work, diagnostic tests, procedures and treatments
• Drugs given and prescriptions filled

SUGGESTIONS FOR RECORD-KEEPING:

• Decide who will be the record-keeper or how the task will be shared.
• Seek the help of a relative or friend. This could be especially important for people who live alone.
• Set up a file system in a file cabinet, drawer, box or three-ring binder.
• Check all bills and explanations of benefits for accuracy.
• Review bills promptly after receiving them.
• Save and file all bills, payment receipts, records of checks and proof of online payments.
• Keep a daily log of events and expenses; a calendar with space for writing is useful.
• Maintain a list of phone numbers for cancer care team members and other contacts.

Handling a Claim Denial or Refusal to Cover a Prescribed Service

It is not unusual for particular claims to be denied or for insurers to say they will not cover a test, procedure or service ordered by a patient’s doctor. If this occurs, it is important to have a working relationship with a case manager who can discuss the situation.

First, patients should ask their doctors to write a letter explaining or justifying what has been done or requested. Then, patients should resubmit the claim with a copy of the denial letter and the doctor’s explanation. Sometimes the test or service will need to be “coded” differently.

If challenging the denial in this way is not successful, then patients might need to:

• Postpone payment until the matter is resolved.
• Resubmit the claim and request a review.
• Ask to speak with a supervisor who has the authority to reverse a decision.
• Seek help from the consumer services division of the state insurance department or commission.
• Consider taking legal action.

What Health Care Reform Means to People With Cancer

THE AFFORDABLE CARE ACT OF 2010 guaranteed certain levels of coverage to patients, survivors and families. At the outset of 2017, the law continued to:

• Require all health plans sold in the health insurance marketplace to cover essential benefits including cancer screening, treatment and follow-up care.
• Make cancer screenings and other preventive care, such as mammograms and colonoscopies, available at no cost to people in new plans, in Medicare or newly eligible for Medicaid.

FOR PATIENTS IN NEW health insurance plans, the law:

• Makes coverage available for patients who participate in clinical trials.
• Prohibits yearly and lifetime dollar limits on care and benefits.
• Disallows higher charges for people who are ill.
• Prevents denial of coverage because of a patient’s medical history.
• Limits the amount patients must pay in out-of-pocket costs and deductibles.
• Requires that children and adults with pre-existing conditions, such as cancer, be covered, and allows children to be covered under their parents' plans until age 26.
• Bans cancellations, meaning that insurers can no longer rescind (or stop) coverage because a patient gets sick.
• Gives patients rights to appeal claims that are denied by their insurers.

For Those Who Are Uninsured

Patients should make sure they keep originals of correspondence. The cancer care team or doctor’s office staff might help make copies if needed. Also, patients should keep a record of dates, names and conversations they have about the denial.Patients who are uninsured could qualify for financial help to buy a health plan sold on their state’s health insurance marketplace. If their income is below a certain level, they might be eligible for coverage through Medicaid (eligibility varies by state). Some states have chosen to broaden access to Medicaid coverage under the health care law, while others have not.