Health insurance helps pay for costly medical treatment and can protect you and your family from financial hardship. Some people have private health insurance coverage either through an employer (often called a group plan) or through an individual policy they've purchased. Even if you have coverage, however, certain treatments and charges may not be covered or paid in full. And there's the potentially overwhelming task of filing or appealing health insurance claims, especially when you're undergoing cancer treatment.
Understanding Your Coverage
Read your policy carefully to understand which services are covered and the portion of medical expenses you'll be responsible for paying. Your expenses may include:
- Premiums: the cost to have the health insurance plan. Premium payments are usually made monthly.
- Deductibles: a fixed amount of money that you must first pay out of your own pocket each year, before the insurance plan will start to pay for your medical expenses.
- Co-payments: a fixed amount that you must pay at the time you receive medical care or prescription drugs. Co-pay amounts aren't applied to the insurance plan deductible amount(s). Co-pay amounts may vary depending on whether you're seeing a specialist (such as a hematologist-oncologist) or a primary care provider, or if you are taking a brand name drug rather than a generic drug.
- Co-insurance: the percentage of medical expenses shared by you and the health plan. This is also referred to as a "cost share." For example, if you have an 80/20 plan, the insurance plan pays 80 percent of your covered medical expenses and you would be responsible for the remaining 20 percent of your medical expenses. The co-insurance amount is in addition to any deductibles and co-payments.
Types of Plans
The following general descriptions may vary from your coverage, so always check your own plan description.
- Health Maintenance Organizations
Health maintenance organizations (HMOs) provide plan members with lower costs and coordinated care from a specific list of health care providers, hospitals, and pharmacies. You must use these specific providers in order for your medical care to be covered by the plan. Plan members choose a primary care physician and must get a referral from the primary care physician to see a specialist.
- Preferred Provider Organizations
Preferred provider organizations (PPOs) provide plan members with additional choices in providers, hospitals, and pharmacies. You pay a standard co-pay amount for an office visit. You can choose between an in-plan or non-plan provider, instead of being restricted to designated providers. You can go to a specialist without permission from your primary care physician as long as the specialist is part of your PPO network. A network specialist would be the least expensive choice. If you visit an out-of-network specialist, you may have to pay the entire bill first, then submit a claim for reimbursement. You may have a deductible for out-of-network medical services or you may have to pay the difference between what network doctors charge and what out-of-network doctors charge.
- Point-of-Service Plans
Point-of-service (POS) plans blend the features of HMO and PPO plans. Plan participants can choose the type of provider best suited to their needs each time they seek care. This type of plan lets you obtain care from an in-network provider (HMO) and, at the next "point of service," see a provider who is from the larger network (PPO), but pay more for your medical expenses. With a POS plan, you would usually see your chosen primary care physician first for any medical issues. Your physician would refer you to a specialist if you need one. You could visit a health care provider outside your network and still receive coverage — but substantially less coverage than if you had stayed within the network.
- Exclusive Provider Organizations
Exclusive Provider Organizations (EPOs) are similar to PPO plans in that they provide plan members with reduced costs and members pay a co-pay amount for an office visit. However, members must select providers from a limited list. If the plan member visits an out-of-network doctor, the visit may cost the plan member from 20 to 100 percent of the costs. This plan may be difficult for patients who require a number of unique specialists.
Fee-for-Service (FFS) plans are more flexible, but involve higher premiums and out-of-pocket expenses, as well as more paperwork. Plan members can choose their own doctors and hospitals. Members may visit a specialist without a referral from a primary care doctor. There is usually a deductible that must be met before the insurance company starts paying claims. Doctors are then reimbursed a percentage of the bill (typically 80 percent); members must pay the remaining 20 percent. Members of an FFS plan may have to pay for medical services up front and then submit a claim for reimbursement. FFS plans pay for “reasonable and customary” medical expenses (a reasonable and customary fee is the amount that your healthcare plan determines is the normal range of payment for a specific health-related service or medical procedure within a given geographic area). If a doctor charges more than the average, the plan member must pay the difference.
Protecting Patient Rights
Previously, patients could be denied coverage if they had been diagnosed with cancer (a pre-existing condition), or because they were diagnosed with cancer at some point in the past (health history). A pre-existing condition is an illness or medical condition that was present before an individual's first day of coverage under a health insurance plan.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides a few protections for patients who have pre-existing conditions:
- HIPAA limits the length of time that an insurance company can "look back" into an individual's medical records to determine whether or not they have a pre-existing condition. The maximum "look back" period is six months.
- In most cases, group health plans can't exclude a pre-existing medical condition from coverage for longer than 12 months. If an individual was previously uninsured, but takes a job with an employer offering health coverage, the maximum pre-existing condition exclusion period for medical coverage is 12 months.
- If a patient has "creditable" health insurance (such as coverage in a group health plan, COBRA continuation coverage, Medicare, Medicaid, a state high-risk plan or a public health plan) for 12 continuous months, with no lapse in coverage of 63 days or more, a new group health plan can't impose the pre-existing condition exclusion. This has helped to ease the issue of "job-lock," whereby people are reluctant to switch to a different job or company for fear of losing their health coverage. In this case, there can't be a waiting period or breaks in dependent coverage for a pre-existing health condition. Insurance carriers issue certificates, called "certificates of creditable coverage," that document the time than an individual has been insured. If the employer imposes a waiting period before the employee is eligible for benefits, and the employee is facing a pre-existing condition exclusion period, then those two time periods run concurrently, rather than consecutively.
As of January 1, 2014, patients could no longer be denied coverage for having a pre-existing medical condition or because of their health history, age, or gender.
Reviewed by Joanna Fawzy Morales, Esq. January 2014.
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