Navigating Medical Insurance with a Cancer Diagnosis
Cancer treatments can be challenging for many patients with breast and ovarian cancer. What often adds to this difficulty is paying for them.
It’s rare for health insurance to pay 100% of cancer treatment charges, therefore, patients are left with countless questions such as: How much coverage do I actually have? What will I have to pay out of pocket? Can my diagnosis cause my premiums to go sky high?”
“It’s a struggle for patients to focus on their health if they’re worried about whether they can afford treatment,” says Tierra Kirk, a financial counselor with the Patricia Lynch Cancer Center at Holy Name Medical Center.
“A financial counselor helps take the burden off the patient and his or her family,” explains Tierra. “We help patients understand what their health insurance plan covers, what they have to pay out of pocket, and what options are available to assist them with financial burdens.”
Educate Yourself about Your Coverage
Health insurance coverage varies significantly between providers and individual plans, says Tierra. Typically patients can expect to receive bills from doctors, labs, the hospital, and other providers.
“The first thing I recommend to my patients is to obtain a binder to organize their appointment dates, medical bills, and EOBs (Explanation of Benefits),” says Tierra.
An EOB is sent by health insurance companies to patients. It explains what medical services were billed and paid on the patient’s behalf. It also explains the patient’s financial responsibility for each service.
“An EOB can help a patient keep track of the out-of-pocket maximum, which is the most you have to pay for medical services in a plan year,” explains Tierra. “The insurance company determines the maximum out of pocket for its members. Copays, deductible, and coinsurance are usually applied toward the maximum, and once it’s reached the medical plan will pay 100% of covered medical services.”
The key to navigating insurance after a diagnosis, she says, is knowledge: “The more information you have about what your insurance allows and covers, the more comfortable you will be.”
Important Questions to Ask
It’s vital, Tierra says, to ask about benefit limitations or exclusions. For example, you should ask if your doctor and treatment center are in your medical network. Or, does your plan require you go to a specific facility or clinic? Will you be eligible for hospital care, home care, or both?
Most importantly, find out about your individual medical coverage for medications that are administered or infused within the hospital. If you have prescription coverage, it usually will only cover outpatient medications.
Medications involved in cancer treatment can be quite expensive and can increase your out-of-pocket expenses. If you have limited medical coverage, there may be additional options available to reduce your financial responsibility. “Patient Assistance Programs, for example, can help offset the amount you have to pay for high cost-medications,” says Tierra. It is also a good idea, she says, to ask your insurance company if it offers a case manager to help navigate your individual care.
Meet Face to Face with Your Support Team
If your health insurance is through your employer, another step to take is making an appointment with your company’s Human Resources representative to discuss your benefits in relation to your employment status. “He or she can explain your short- and long-term disability benefits, as well as eligibility for COBRA coverage, if necessary,” explains Tierra.
“I have found that an educated patient experiences less financial distress,” notes Tierra. “Therefore, I highly recommend that upon receiving a cancer diagnosis, a patient ask his or her physician about meeting with a financial counselor to discuss medical benefits.”
To Obtain Assistance
Sharsheret and Holy Name Medical Center are partners with a common mission: To increase awareness and provide resources, including financial understanding, for patients with breast and ovarian cancer and their families.
Sharsheret’s Financial Wellness Tool Kit helps empower patients to learn how to successfully navigate the often complicated issues of health insurance, disability rights, financial planning, and estate planning. To order this tool kit and find out more about the help that is available please visit:
Holy Name’s Financial Counseling office screens eligible Holy Name patients for government-sponsored coverage, such as NJ Family Care and other NJ Medicaid programs. For Bergen County residents, a part-time county employee is stationed at Holy Name to help process NJ Family Care and Institutional Medicaid applications for eligible patients who receive treatment at the medical center. Patients can contact Holy Name’s Financial Counseling office at 201-833-3157 to be pre-screened by phone.