Newly Diagnosed with Cancer: Navigating Health Insurance
After the doctor tells you that you have cancer and discussed your care, it is time to call your insurance company to find out what your health insurance policy covers and what it DOES NOT.
Perhaps you have been lucky and have only needed to use your health benefits for minor problems. Having cancer can routinely cost thousands and thousands of dollars.
You need to check with your insurance company or have someone you trust do it for you. Do not assume your doctors, nurses or social workers know your policy and have the answers. The name of the insurance company may be very familiar, but there can be many different policies within the same company and the coverage your friend has may not be the same coverage you have.
Understanding your health insurance benefits can be difficult even after talking to a customer service representative at your insurance company.
Tips for Talking with Your Insurance Company
- Ask the insurance representative to explain words you do not understand and then have them give an example. It is okay to ask the same question several times as well as to call back and talk with another person. People may use different words to explain the same thing.
- Have a notebook handy. Write down information given to you, the name of the person speaking, along with the date and time of your conversation. (Insurance companies tape record conversations. If there is an issue, it is possible to check the records.) Repeat the information back to the representative and confirm you have written down the information correctly.
- Like any person, the insurance representative may be kind and helpful or impatient and rude. Don't be afraid or let this stop you from receiving and understanding your insurance information. It is your right to know what will be covered and what won't be.
- Find out which physicians, hospitals and clinics are covered by your insurance. This is sometimes referred to as "in-network provider." Sometimes insurances pay for "out-of-network" providers but do not provide the same amount of coverage.
- Find out what makes a benefit year for insurance purposes as it is not always the same as a calendar year.
- Do you have prescription coverage? Is there a separate deductible for medications?
- Do you need to have prior authorization before having treatment or tests are done? Find out, because if you do need prior authorization, but don't have it, you could end up paying for the treatment/tests yourself.
- Check your insurance documents/handbook to see if the information is the same given to you by the customer representative. There is also a document (usually called a certificate of insurance) which spells out in specific detail what your insurance does cover. A certificate of insurance is not the same as a handbook.
- If you think your insurance has made a mistake, call and talk about it. If this doesn't work, ask for an appeal and what you need to do to get one started. Unfortunately there have been companies who automatically deny an appeal. Pursue it if you believe you are right
Helpful List of Common Insurance Terms
CO-INSURANCE is a percentage of the total charge that you are required to pay. If there is a $100 charge and you pay 10% co-insurance, you will pay $10.
CO-PAYMENT is a pre-determined dollar amount that you pay no matter what the total cost of the services. If the copayment is $15, you pay $15 regardless of the charge.
DEDUCTIBLE is a pre-determined dollar amount that the member must pay out-of-pocket before insurance pays for certain services.
OUT-OF-POCKET LIMIT is the most the member must pay-out-of-pocket during the year. Some services do not apply to out-of-pocket limit.
Susan Brye, CICSW, is an oncology social worker in the UW Carbone Cancer Center. She offers a variety of free services to help those with cancer and their loved ones. Services include, but are not limited to, finding ways to cope with the cancer diagnosis, understanding federal and state disability benefits, searching for local resources, work place issues and support.