Health Insurance for Cancer Treatment: What to Know

Health insurance for cancer treatment

In some ways, a battle with cancer today goes well beyond fighting the disease itself. Patients also face the hardship of affording increasingly expensive treatments on top of all the usual bills. And if that isn’t bad enough, it looks like the costs of cancer treatment aren’t coming down anytime soon. A study from 2014 found the annual cost of a cancer drug was over $120,000, and estimated that it would continue rising each year by 7.5 – 10.5% until at least 2020.

Health insurance can help cover some of these costs. Unfortunately for some patients, their insurance plans are proving to be limiting when it comes to treatment options, or just simply not enough to cover such high expenses. Though the Affordable Care Act (ACA) – also known as Obamacare – has been able to help cancer patients in certain situations, its future remains unclear under the new Trump administration as they develop and push for their health care reforms.

Patients can’t simply hold off on treatment until it’s more affordable when faced with a life-threatening diagnosis. Understanding your own insurance policies and other avenues of financial assistance can help lessen the stress of high medical bills.

Better Coverage for Cancer Patients

The ACA passed in March 2010 and has helped cancer patients in a number of ways. First, it allowed many families the opportunity to get coverage that previously didn’t have the ability to easily do so. Though insurance coverage may not completely cover treatment costs, it can certainly make a huge difference compared to paying completely out-of-pocket.

Before the ACA, depending on their insurance plan, patients with preexisting conditions, including a cancer diagnosis, could be denied insurance or denied coverage for their treatment. The law now forbids insurance companies from denying coverage based on preexisting conditions, with a few very rare exceptions. The ACA also prevents rescission, or dropping coverage of a policy holder upon learning they are sick.

The ACA has also helped cancer survivors and younger cancer patients. Prior to its passing, private insurance companies could limit the amount of coverage a patient received over their lifetime. This could be devastating for a cancer survivor, as their healthcare costs extend well beyond initial treatment. If an insurance company placed limits on how much it would pay for a patient in their lifetime, any followup scans or later treatment in the case of recurrence would likely not be covered.

Unfortunately, ACA doesn’t solve every limitation of coverage. Many policies are considered “grandfathered plans” because they were in effect before the ACA passed. In these instances, the plans don’t have to abide by these new rules or others laid out by the ACA unless they later make adjustments to their plan. But even with the ACA in place, there are no guarantees for how well an insurance plan can cover such high costs.

Understanding the Costs Covered By Insurance

There’s a lot of variation in what insurance policies cover. People can be insured through private insurance agencies or government programs like Medicare and Medicaid. Private insurance has two basic care models: health maintenance organizations (HMO) and preferred provider organizations (PPO).

Regardless of type, most plans cover basic benefits such as annual checkups, hospitalizations, preventive care, and prescriptions. Out-of-pocket payments will vary based on the deductible, co-pay, or coinsurance amounts of individual plans. Under private insurance, there are often limits placed on what doctors and hospitals are considered “in network.” Though a patient can see a specialist or doctor outside of that network, it will cost more.

Sometimes the plan will also require preapproval for out-of-network visits. For patients diagnosed with mesothelioma, a rare cancer, they likely need to travel to seek the help of a specialist. Mesothelioma specialists are scattered around the country, and in many cases it could be difficult to find one that’s in-network. Not only would patients have the secondary costs like travel and lodging to seek help, but they would also likely pay more for an already expensive cancer treatment.

Expenses can pile up even before treatment begins. For example, seeking a second opinion can mean a high out-of-pocket expense for some patients. Many insurance policies will deny coverage for additional tests or scans if those tests were already part of the initial diagnosis or if they are deemed medically unnecessary. A single diagnostic imaging scan can cost anywhere from $800 – $1600, which can start adding to the medical bills quickly.

The American Cancer Society recommends keeping records of medical bills, reimbursements, and anything insurance wouldn’t cover. It’s also a good idea to keep track of other expenses related to treatment, such as travel, clinic visits, and any kinds of testing or procedures. This can help appeal decisions by the insurance company to not cover certain expenses.

Insurance and Clinical Trials

Patients who don’t see the desired results from standard treatment often seek to participate in a clinical trial, which is a study of a promising new treatment.

With clinical trials, the two primary types of costs are patient care costs and research expenses. Patient care costs include doctor visits, hospital stays, standard cancer treatment, and treatment for any side effects, as well as any lab work or imaging tests. Insurance will typically cover these routine care expenses while in a clinical trial if:

  • The patient is eligible for the clinical trial;
  • It is an approved clinical trial, meaning it is federally funded and the researchers have submitted an application for the drug to be FDA approved; and
  • The trial does not involve out-of-network doctors and hospitals.

Research costs are the expenses related specifically to the study itself. This generally includes the drug being studied and any lab work or imaging tests performed solely for the trial. Clinical trials also often include extra doctor’s visits and possibly hospitalizations, which may not be covered because it goes beyond the care of standard treatment. In many cases, however, part or all of the research costs are covered by the study’s sponsor.

Again, any policies that were grandfathered in before the ACA passed can deny the costs of routine care for a patient while they are in the clinical trial. Under the ACA, an insurer cannot deny a patient the right to join a clinical trial if they are eligible or limit their coverage for the routine costs of care.

Seek Help with Mesothelioma Treatment Costs

Cancer treatment is very expensive and the costs only seem to continue to climb. With the rising cost of cancer drugs and uncertainty with how healthcare might change in the future, more needs to be done to help cancer patients now. Healthcare providers, insurance agencies, and governmental agencies need to work together to find a solution so patients can better afford treatment and get the care they need.

In the meantime, if you or a loved one has been diagnosed with mesothelioma, talk with someone to find out what options may be available beyond insurance to help you pay for your cancer treatments.