Paul Sanchez
Cancer is a life-altering diagnosis that can bring about many changes, including financial ones. It is important to understand your insurance coverage, especially in the case of a serious illness. While the Affordable Care Act (ACA) mandates coverage for essential benefits, there may be gaps in your insurance coverage for cancer treatment, including medication. Understanding your insurance plan and what costs are covered is crucial, as is keeping your insurance up to date with no lapses in coverage. Additionally, certain treatments and medications may not be covered by your insurance provider, leaving you with unexpected out-of-pocket expenses.
| Characteristics | Values |
|---|---|
| Cancer treatment costs | Can be very expensive |
| Insurance coverage | Depends on the type of insurance and the insurer |
| Workplace protections | Federal and state protections provide time off work for cancer treatment |
| Employer-based insurance | Usually offers several kinds of health benefits |
| Coverage gaps | Should be avoided |
| Out-of-pocket expenses | Vary depending on the insurance plan |
| Prior authorization | Required for some treatments |
| Financial assistance | Available through caseworkers, financial counsellors, or social workers |
| Supplemental insurance | Can help cover costs not covered by primary insurance |
| Treatment costs | Vary depending on cancer type, stage, and location |
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What You'll Learn
Cancer treatment costs
The cost of cancer care varies depending on the type of cancer, the phase of treatment, and the patient's insurance coverage. On average, cancer treatment costs are highest in the end-of-life phase, followed by the initial phase and then the continuing phase. For example, the per-patient annualized average costs for medical services were $109,727, $43,516, and $5,518, respectively, for these three phases. Oral prescription drug costs also vary by cancer type, with the highest annualized average costs for chronic myeloid leukemia (CML) and myeloma across all phases of care.
Nationally, the cost of cancer care in the United States is substantial and projected to increase. In 2015, national cancer-attributed medical care costs were estimated at $190.2 billion, and this figure is expected to grow to $208.9 billion in 2020 due to population changes alone. By 2030, the American Cancer Society (ACS) estimates that the cost of cancer care will reach $246.6 billion, while another study projects it to exceed $245 billion. These estimates reflect the rising healthcare expenditures associated with cancer treatment, which have become a critical topic in patient-provider discussions.
Managing the financial burden of cancer treatment can be challenging, but there are strategies to help. Patients should review their insurance coverage and understand what services are covered and what costs they will owe. It is essential to keep insurance coverage up to date and avoid lapses. Additionally, patients can call their insurer before planned medical services to see if prior authorization is needed and ask about all potential out-of-pocket costs. For those with limited finances, cancer care teams can provide assistance through caseworkers, financial counselors, or social workers. Furthermore, patients can explore options like employer-provided leave benefits, the federal Family and Medical Leave Act (FMLA), and state-level protections to take time off work for treatment and recovery without losing their job.
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Workplace protections
If you or a loved one has cancer, you may be protected by federal and state laws in your workplace. The Family and Medical Leave Act (FMLA) provides up to 12 weeks of unpaid, job-protected leave in a 12-month period for certain family and medical reasons, including cancer treatment, recovery, and care. This includes time off before a cancer diagnosis and ongoing care when the cancer is in remission. If your employer provides group health insurance coverage, you have the right to continued coverage during FMLA leave on the same terms as if you had continued to work. When you return from FMLA leave, your employer must provide you with the same job or one that is virtually identical in terms of pay, benefits, and other working conditions.
The Americans with Disabilities Act (ADA) prohibits employers with 15 or more employees from discriminating against employees or qualified job applicants based on disability, including cancer. Under the ADA, you have the right to health privacy; your employer may not disclose your cancer diagnosis to your co-workers, even if you voluntarily disclose it. Limitations from cancer treatment side effects are considered disabilities under the ADA, so employers must provide reasonable accommodations, such as setting work breaks to take medication or see a doctor.
If your employer-provided insurance does not cover your cancer medication, you may be able to shop on the Marketplace and get premium subsidies if your coverage at work costs 8.39% or more of your household income. It is important to keep your health insurance up to date with no coverage gaps and to call your insurer before planned medical services to see if you need prior authorization.
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Employer-based health insurance
If your employer offers health insurance, it is important to check the different options available for you and your family members. When you start a new job, there is usually an enrollment period where you can look at your options and choose your health insurance plan. Some employers offer health coverage that starts on your first day of work, while others may have a waiting period of 30 to 90 days. After this, there is usually an open enrollment period once a year, during which you can update or change your health benefits.
It is very important for anyone with cancer to have a health insurance plan that covers the costs of cancer care. If your employer offers group health insurance coverage, you have the right to continued coverage during any leave on the same terms as if you were still working. This is also the case if you need to take time off to care for a family member who is ill and receiving medical care prior to a cancer diagnosis or receiving ongoing care when the cancer is in remission. Under the Americans with Disabilities Act (ADA), an employer must consider providing unpaid leave to an employee with a disability, as long as it does not create an undue hardship for the employer.
If you are unable to get insurance through your employer, you may be eligible for a state high-risk insurance pool or a major risk plan. As of 2014, the Patient Protection and Affordable Care Act (ACA) allows anyone to shop for insurance in their state's Health Insurance Marketplace, and insurance companies can no longer deny selling a policy or charge more because of a pre-existing condition. If your income is low enough, you may be able to qualify for help with premiums or other costs, or you can shop on the Marketplace and get premium subsidies.
If your doctor accepts your insurance, their office will often bill the insurance company for you and then send you a bill for the amount not covered. Before you get a bill, you should receive an Explanation of Benefits (EOB), which includes the services you received, the amount your insurance will pay, and the amount you will owe. It is important to review this so that you can look into any issues before you get a bill, and to keep all paperwork related to your claims.
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Out-of-pocket expenses
Dealing with a cancer diagnosis is challenging, and the financial burden of treatment can be overwhelming. Even with a good health insurance plan, patients and their families may face significant out-of-pocket expenses. Out-of-pocket expenses refer to the costs that patients must pay directly for their healthcare, and these costs can quickly add up for cancer patients, especially when the disease and its treatment are complex and prolonged.
For cancer patients, out-of-pocket expenses can include co-payments for hospital bills, prescription drugs, chemotherapy, other medications, and doctor visits. Additionally, there are non-medical costs, such as travel expenses to and from treatment centres, caregiver costs, and taking time off work. These costs can be substantial, and a systematic literature review found that cancer patients and caregivers in high-income countries (HICs) spent, on average, 16% of their annual income on out-of-pocket expenses related to cancer care. This percentage was even higher in low and middle-income countries (LMICs), with an average of 42% of annual income spent.
To manage these expenses, it is essential to understand your insurance policy guidelines and charges, including co-pays, deductibles, and coinsurance. Knowing what services are covered and what costs you owe can help you prepare financially. It is also beneficial to ask upfront about all out-of-pocket costs and request payment plans to spread out the financial burden. Additionally, consider working with a financial counsellor who can help you navigate your insurance policy and manage treatment costs.
In the United States, there is a limit on what most private insurance plans can require enrollees to pay in out-of-pocket costs, known as the maximum out-of-pocket limit or MOOP. This limit changes annually and protects patients from extremely high costs. For example, in 2022, the MOOP for an individual plan was $8,700, while for a family plan, it was $17,400. It is worth noting that this limit does not include premium costs or expenses for non-covered or out-of-network services.
To summarise, while insurance can provide financial support during cancer treatment, patients and their families should still expect out-of-pocket expenses. Understanding these costs and seeking support from financial counsellors can help ease the financial burden during an already challenging time.
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Supplemental cancer insurance
There are several types of cancer insurance policies, including expense-incurred policies, which pay a specific percentage of treatment costs up to a defined limit, and lump-sum policies, which pay a fixed amount of money after a cancer diagnosis. This can be used for any costs, including medical and non-medical expenses, and is usually paid directly to the recipient.
The cost of cancer treatment is hard to predict and can be challenging to cover without insurance. The average cost of medical care and drugs to treat cancer is more than $42,000 in the year after diagnosis. Cancer insurance premiums are generally affordable, with some policies costing less than $1 per day.
When considering cancer insurance, it is important to keep your health insurance up to date with no coverage gaps and to review the different options available to you and your family members. It is also beneficial to call the insurer before planned medical services to see if prior authorization is needed and to be aware of any out-of-pocket expenses you may incur.
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Frequently asked questions
Cancer can be very expensive to treat, and it is important to have a health insurance plan that covers the costs of cancer care. You can look into supplemental cancer insurance to help cover out-of-pocket expenses. If your insurance is provided in accordance with the Affordable Care Act (Obamacare) or you have Medicare, your coverage will include cancer treatment. If your finances are limited, you can ask your cancer care team for help from a caseworker, financial counsellor, or social worker.
Out-of-pocket expenses refer to the costs you owe after insurance. This includes co-insurance, which is the percentage of each medical bill you pay after your yearly deductible amount, and the out-of-pocket maximum, which is the highest amount you pay each year before your insurance pays for 100% of covered services.
If your coverage at work is more than 8.39% of your household income, you can shop on the Marketplace and get premium subsidies. You can also look into cancer insurance, which can provide cash benefits to help with out-of-pocket expenses.
When you start a new job, there is usually an enrollment period where you can look at your options and choose your health insurance plan. You can also shop on the Marketplace if the family or dependent health coverage costs are too high at work.
If your insurance denies coverage, you can appeal the denial. If your treatment involves plastic or reconstructive surgery, you can argue that there is a medical and functional necessity for the procedure. If your treatment involves medication for a type of cancer for which the drug has not been approved, your insurance may view this as experimental and deny coverage.
