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I'm worried about the financial implications of my cancer treatment. How can I best navigate my insurance to understand what is covered? I'm a financial analyst and I still can't figure out how to understand the details of my plan.
- Felix Li(Insurance Navigator)•
I'm sorry to hear about your diagnosis. I'm glad you reached out to ask about financial implications since there are some steps to getting a better understanding of what is happening.
Familiarize yourself with the Summary of Benefits Coverage (Aka SBC): This will give you an overview of what services are covered and at what coverage. There might be some info on cancer coverage in the SBC but you will likely need to go deeper into the policy. Key concepts to understand at this point are:
- co-pay: a fixed amount of money you pay out-of-pocket for a specific healthcare service
- co-insurance: a percentage of the total cost of a healthcare service that you're responsible for paying
- deductibles: the amount of money you have to pay out-of-pocket for healthcare expenses before your insurance coverage begins
- in-network vs. out-of-network: In-network providers have negotiated lower rates with your insurance company, so you usually pay less out of pocket
Budget around the out-of-pocket maximum: While you can find some publicly available data on the cost of treatments that could allow you to calculate anticipated costs. One simplification is budgeting around the out-of-pocket (OOP) max. This is the maximum amount you will pay across deductibles, co-pay and co-insurance before the insurance company covers everything. However, it is important to remember there is a different OOP max for in-network, out-of-network, individuals and families. Also, treatments that are not covered by the insurer generally do not count towards the OOP max. Finally, it's important to account for other costs like transportation, accommodations and childcare depending on your situation.
Contact your insurance provider: The quickest way to understand your coverage is often to contact your insurance provider directly. They can explain the specifics of your policy, such as whether certain treatments, medications, or specialists are covered.
Determine the need for specialist referrals: If your treatment requires you to see a specialist, check whether your insurance plan requires you to get a referral from your primary care physician first.
Check for preauthorization / prior authorization requirements: Some treatments and procedures may require you to get approval from your insurance company before they will cover the cost. If this is the case, ensure that your healthcare provider gets this authorization on your behalf.
Understand which prescription drugs are covered: If you'll be taking prescription drugs, find out how they are covered. Some insurance plans have formularies, or lists of preferred medications, that they cover more fully than others.
Appeal decisions: If your insurance company denies coverage for a treatment your doctor recommends, understand the process for appealing that decision. You may need your doctor's help in making a case for why the treatment is necessary.
Document everything: Keep records of all communications with your insurance company, including the names of the people you speak with, what was said, and any decisions that were made. With consent from other parties, you can use apps like Abridge that specialize in documenting medical conversations.
Navigating insurance can be complicated, but you're not alone. If you're having trouble you can always reach out to our team for additional support.