Information for Survivors – Health Insurance
Health Insurance Guidance & Tips for Survivors
Everyone needs dependable health-insurance coverage, but it’s especially important for cancer survivors. Not only do you need to have health insurance,, it is important that you maintain continuous coverage. A lapse can result in refusal of a new policy to cover pre-existing conditions. You need to understand your insurance policy and know your rights. The current health care reform has changed the way a person can obtain coverage. Because there are so many healthcare reform changes, it is impossible to cover all of them here. A great resource to learn about the new healthcare reform is www.healthcare.gov which outlines many of the provisions passed in legislation. In addition to the current reforms, the following types of health insurance are available to you:
Employer Provided Insurance
Most health insurance provided by employers is a form of managed care. This approach provides healthcare services in the most cost-effective manner. Below are some of the more common managed-care models:
- Preferred Provider Organization (PPO)
- Point of Service Plan (POS)
- Health Maintenance Organization (HMO)
- Health Savings Account (HAS)
If your employer does not offer healthcare coverage, or if you are self-employed, investigate group health care policies through other organizations, such as labor unions, fraternal organizations, professional or business organizations, student associations, religious groups, or other special-interest groups. The Encyclopedia of Associations, found at most public libraries, includes information on groups that offer insurance coverage. Be sure to investigate any insurance carrier with your state’s regulatory office; as in any industry, beware of fraudulent insurance providers.
State and Federal Programs
In addition, you may qualify for state or federal health insurance. Currently, state and federal laws offer cancer survivors very limited help in obtaining health insurance, but advocates are working toward improving this situation.
Listed below are government-sponsored programs you may qualify for:
- State Children’s Heath Insurance Programs (S-CHIP)
The NCCS offers a free discount prescription drug card that also generates donations for the organization. The NCCS card provides users significant discounts on prescription medications at over 57,000 participating pharmacies nationwide and is designed for those who have limited or no prescription drug coverage. Click here to get your free card and find a participating pharmacy near you.
It is important that you check on your current health insurance and investigate that you are receiving the proper coverage based on the current legislation.
Making the Most of Your Health Insurance
Throughout your life you will need to understand the ins and outs of your insurance policy. Here are some specific questions you should be able to answer:
- Which doctors and hospitals are included in your provider network?
- When do you have to get authorization prior to treatment?
- Does your prescription coverage include name-brand or generic drugs, and how much of the cost is covered?
- What inpatient and outpatient treatments are covered?
- Does your policy have a lifetime maximum or ‘cap’ for treatment?
- Does your insurance cover any ancillary expenses (lodging, meals or transportation)?
- Does your insurance operate on a reimbursement basis, or will the providers send invoices?
- Who is your contact person at the insurance company? Whom should you contact regarding denials?
To be an effective advocate for yourself, you should keep the following information for your records:
- Keep a copy of everything related to your medical treatment. This includes all authorization forms, explanation of benefits (EOB) forms, all communication with the insurance company and any communication regarding bills and payments.
- If your provider is responsible for sending invoices, ensure that this happens in a timely manner. You may have to verify with the doctor’s office that this has happened a week or two after the appointment.
- Compare your dates and services provided to the EOB you receive.
If your insurance company denies a claim, investigate the reason. Many denials are due to errors. For example, the doctor’s office may have miscoded an item, or the bill may have been sent out late. If you see a problem, contact the provider’s billing office or the insurance company. When the mistake is corrected, the insurance company will reverse its denial.
Understand your insurance coverage and track your appointments, authorizations, communications and EOBs. The paperwork may seem overwhelming, but it’s essential for battling erroneous denials.
If you receive a denial that isn’t the result of a billing error, you may still want to appeal the decision. Make sure you know the insurance company’s time frame for appeal, and take the following steps. If you need help, contact the Patient Advocate Foundation or a similar organization. Steps to take:
- Obtain a written copy of the reason for the denial. Denials occur for a variety of reasons, but typically are triggered by procedures the insurance company deems outside the standard of care.
- Check your insurance guide. If the guide states the procedure is covered, contact the insurance company to clarify.
- If the insurance denial states “not standard of care or experimental,” as the reason for denial, ask your doctor to send an explanation of the treatment to the insurance company and follow up yourself. Insurance companies are not always aware of the latest treatment procedures. Your advocacy will assist future patients.
If your insurance company persists in issuing what you consider an unjust denial, consider contacting a third party, such as the Patient Advocate Foundation or your state insurance commissioner.
Understanding your health-insurance policy may be a challenge. If you have questions, contact your state insurance commissioner’s office or the U.S. Department of Labor, which regulates health plans offered by many large employers. In addition, you can get a free review of your policy by contacting the Patient Advocate Foundation at 1-800-532-5274.