It is important for cancer survivors – like everyone else – to have adequate and dependable health insurance. There are many kinds of policies on the market, though not all offer the same protection.

It is best to have comprehensive health coverage that will pay for all of your basic health-care needs such as hospital and doctor care, lab tests, medical equipment, and prescription drugs. When evaluating a policy to see if it meets your needs, in addition to looking at the premium, you need to consider:

• What services are covered?
• How much will I have to pay for covered services?
• What type of policy is it and from whom can I get care?
• What Cancer Survivors Need to Know About Health Insurance

What services are covered?

Look at the list of services the policy covers. Look also at what services are explicitly excluded from the policy. For example, many policies exclude coverage for care in clinical trials, drugs that are not on a formulary or approved list, and other important services. Many policies also temporarily exclude services related to a pre-existing condition. And some add “riders” that permanently exclude services relating to a specific condition, organ system, or body part.

When considering a policy, it is important that you find out whether the services you may need during your cancer treatment are covered by the plan. If you are considering joining a managed care plan, you should also find out whether your current doctors belong to the plan’s network. Many cancer patients have developed a strong relationship with their doctors and may want to continue receiving treatment from them.

Remember, however, that just because your doctor is a member of a certain network today does not guarantee that he or she will remain in that network forever. Also, it is important for you to review the policy to find out what steps you will have to take in order to see a specialist.

How much will I pay for covered services?

The amount of money you pay to purchase health insurance is called a premium. When considering a health insurance policy, look also at the annual deductible (the amount you pay each year before coverage kicks in). Some policies also have separate deductibles for certain services, such as hospitalization or drugs. Look, too, at the copayment (a flat fee, such as $10 or $20, that you pay the provider at the time of service) and coinsurance (a percentage of the bill that you pay) that apply to covered services.

Also, watch out for balance billing – something that happens when the plan limits its payment to the part of the fee that it considers reasonable, leaving you responsible for the rest. See if your policy requires doctors and hospitals to accept the plan’s payment as payment-in-full. Most policies have an out-of-pocket limit or “stoploss” feature that caps the amount you have to pay in deductibles, coinsurance, or copayments.

After that, the plan pays 100 percent. However, the out-of-pocket limit usually does not apply to balance billing. Finally, policies often have a lifetime limit or lifetime maximum on covered benefits (such as $1 million). Some also impose annual limits on what they will pay.

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Different Types of Policies

Fee-for-service, or indemnity policies, are what people think of as traditional insurance. Under these policies you choose your own doctor or hospital and the insurance company pays a portion of your bill after you meet your deductible. Managed care policies, by contrast, usually require you to get care from their network of participating providers, including doctors, hospitals, and pharmacies.

In addition, managed care plans often require their members to designate a primary care provider (PCP ) or “gatekeeper” who must provide a referral for any visits to a specialist, even a specialist in the plan’s network. These types of plans are most commonly referred to as health maintenance organizations or HMO s. There are advantages and disadvantages to managed care plans. These include:

Advantages

• Lower cost to you (premiums and out-of-pocket costs).
• No claims for you to file.
• Coverage for preventive and routine care.

Disadvantages

• Limited choice of health professionals, pharmacies, and hospitals.
• Care from specialists may require a referral from your primary care provider (PCP).
• Limited or even no coverage for out of network care.

There are hybrid policies, sometimes called preferred provider organizations (PPOs) or point-of-service options (POS), that offer more flexibility than traditional managed care plans by allowing you to have a choice of getting care from in- or out-of-network providers, often without pre-approval. You should be aware that you usually pay more – sometimes a great deal more, including balance billing – for care received out of network.

In addition to the types of comprehensive coverage described above, there are other kinds of health insurance policies. Cancer survivors should be especially careful to understand what these policies are about:

Catastrophic Insurance

Catastrophic policies are limited policies that cover very high medical expenses. Catastrophic policies have very high deductibles. Some people who buy catastrophic policies also open taxfavored health savings accounts (HSA s) to put aside funds to cover these high deductibles. These policies usually are not a good deal for cancer patients.

Long-Term Care Insurance

Long-term care insurance provides you with a daily benefit when you can no longer take care of yourself. Whether you live at home, in an alternate care facility, or even a nursing home, a good policy will cover skilled, intermediate, or custodial care. However, the companies that sell these policies require that you be in fairly good health when you purchase them. For cancer survivors, that generally means at least five years past treatment. Companies may also consider the type of cancer you had when deciding whether you qualify for coverage. Premiums depend on your age and health.

Short-Term, Non-Renewable Policies

Short-term, non-renewable policies, as the name implies, offer coverage only for a limited time (e.g., for 6 months). If you get sick during that time, the insurer can refuse to renew your coverage. Short-term policies can help bridge a gap in insurance coverage and may be a good idea if you are fairly certain that another, more stable source of coverage will be available in the near future. However, these policies should not be mistaken for comprehensive coverage that is guaranteed renewable.

Cancer Insurance

Cancer insurance or other limited benefit policies only pay for costs related to treatment for cancer or other specific diseases. Insurers generally will not sell these policies to cancer survivors and many states have banned or restricted their sale. Most insurance experts recommend buying a good comprehensive policy instead of cancer insurance for the following reasons:

• Comprehensive insurance usually covers the cost of cancer treatment; additional cancer policies usually duplicate coverage from other policies and are an unnecessary expense.
• The premiums for cancer policies are high and the benefits are limited. Cancer policies often do not cover complications from cancer treatment.
• Some insurance companies and agents try to mislead consumers and prey on their fears about cancer.
• Sales and administrative expenses for cancer policies tend to be much higher than for other policies.

Accident-Only Policies

Accident-only coverage, as the name implies, pays only for care that you need as a result of an accident, not care that is due to illness. Since a good comprehensive policy will cover costs associated with accidents as well as costs related to illness, accident-only policies are not a good value.

Supplemental or Hospital Indemnity Insurance

Supplemental insurance or hospital indemnity policies pay a cash benefit for each day you are in the hospital. The cash benefit will be nowhere near the cost of hospital care, though. These policies are relatively inexpensive and simple to buy and may be appropriate if you want them to cover “extras” that come up when you get sick. But they should never be confused with comprehensive coverage.

Public Coverage

Sometimes you can get health insurance from the government, instead of a private employer or insurance company. Usually you can only get public coverage if you qualify based on your age, your income, or your health status. Medicare and Medicaid are the biggest public programs and are available in every state. In a few states, there are other smaller programs that might be able to help you buy affordable health insurance.

Children’s Health Insurance Program

In addition to Medicaid, the State Children’s Health Insurance Program (S-CHIP) offers health insurance coverage to low income, uninsured children under the age of 19. Children can qualify for this free or subsidized health insurance if their family’s income is twice as high as the federal poverty level, although in some states, kids in families with incomes up to 400% of the federal poverty level can qualify. (In 2006, the poverty level for a family of 3 was $16,600 except in AL and HI.) Typically, children cannot be in S-CHIP if they are eligible for private health insurance. However, the eligibility requirements vary from state to state. In all states, children who are eligible for both Medicaid and S-CHIP must be enrolled in Medicaid. In some states, the S-CHIP program is part of the Medicaid program; in others, it is a separate program. To learn more about S-CHIP, contact your state public welfare or social services department or your county welfare board.

Other Public Coverage

A few states offer other help for people who cannot afford health insurance. Some offer government-sponsored health insurance that you can buy at discounted premiums if you have low income. A few states have programs that will help you buy coverage from a private insurance company. Thirty-one states have high-risk pools where you might be able to buy coverage if a private insurer turns you down. In several of these states, a modest premium subsidy is available if you have low income.

When it comes to health insurance, the key to remember is read the policy. Whether it is coverage you already have or are thinking of getting, look at the policy carefully to make sure you know what it entails.