Jeffrey Wade
Cancer treatment can be expensive, and many patients with complex diseases like cancer find it challenging to afford their treatments, even with health insurance. The good news is that most public and private health insurance plans are required to cover cancer diagnosis and treatment. However, it's important to note that coverage and out-of-pocket expenses can vary based on the specific plan and the patient's medical needs. Patients should understand their health insurance plans, including covered and excluded services, to navigate the financial aspects of their cancer treatment effectively.
| Characteristics | Values |
|---|---|
| Private insurance coverage for cancer treatment | Most private insurance plans cover cancer diagnosis and treatment, but copays, coinsurance and deductibles may apply. |
| Public insurance coverage for cancer treatment | Public insurance plans are also required to cover cancer diagnosis and treatment, with similar costs to private insurance. |
| Out-of-pocket costs | Cancer treatment often involves high out-of-pocket costs, even with insurance. There are limits on what private insurance plans can require enrollees to pay, and financial assistance is available for those who qualify. |
| Prior authorization | Many insurance companies require pre-authorization for cancer services, so it's important to understand your plan's requirements. |
| Biomarker testing | Most private insurance carriers cover at least some biomarker testing for patients who meet certain criteria. |
| Genetic testing | Insurance may cover genetic testing for patients with tumor test results suggesting Lynch syndrome or another inherited genetic mutation. |
| Fertility preservation | Some states have laws requiring insurance coverage of fertility preservation for cancer patients. |
| Mental health services | Health plans sold on state Marketplaces, through the individual market, or by small employers must cover mental health services. |
| Experimental treatments | Insurers may deny coverage for experimental treatments or those that differ from the standard clinical treatment pathway. |
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What You'll Learn
Biomarker testing and tumour tests
Biomarker testing is a way to look for genes, proteins, and other substances (called biomarkers or tumour markers) that can provide information about cancer. Each person's cancer has a unique pattern of biomarkers. Some biomarkers affect how certain cancer treatments work. Biomarker testing may help you and your doctor choose a cancer treatment. For example, in some types of cancer, people whose cancer cells have certain changes in the EGFR gene can often be helped with targeted drugs known as EGFR inhibitors. Biomarker testing can be done before treatment to find out if a person's cancer cells have an EGFR gene change. This can show if an EGFR inhibitor might be helpful in treating their cancer.
Biomarker testing is different from genetic testing, which is used to find out if someone has inherited mutations that make them more likely to get cancer. Biomarker tests can be paired with a specific treatment and are then called companion diagnostic tests. Tumour tests can also help establish how aggressive the cancer is and whether it's likely to recur. Biomarker testing may be done to determine if a tumour has certain features indicating that the cancer is more susceptible to specific treatments called targeted therapies.
Most private insurance carriers cover at least some biomarker testing for patients with certain cancers who meet established medical criteria. Patients with tumour test results that suggest Lynch syndrome may be referred for genetic counselling and/or testing for an inherited genetic mutation. This is typically covered by insurance but copays, coinsurance and deductibles may apply. It is important to note that short-term, temporary or catastrophic coverage health plans may not cover cancer treatment and can exclude coverage based on pre-existing health conditions.
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 your insurance didn’t cover. Before you get a bill, you should get an Explanation of Benefits (EOB). It’s important to review this so that if there are any issues, you can look into them before you get a bill. Do not pay a bill until you receive the EOB and make sure it is correct. The EOB will include the services you got, the amount your insurance will pay, and the amount you will owe.
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Co-pays, co-insurance, and deductibles
Private insurance plans cover cancer diagnosis and treatment, but co-pays, co-insurance, and deductibles may apply. These out-of-pocket expenses can quickly add up, and it is important to be aware of them and plan for them.
Co-pays, or co-payments, are flat fees that you pay each time you go to your doctor or fill a prescription. The amount you pay is predetermined by your health insurance plan and is usually printed on your health plan ID card. Co-pays are not always applicable, as some plans do not use co-pays to share the cost of covered expenses.
Co-insurance is the percentage of each medical bill that you pay, even after you have paid the yearly deductible amount. The higher your co-insurance percentage, the more you will pay. For example, if your co-insurance is 20%, you will pay $20 for a $100 cancer drug.
Deductibles refer to the amount you pay before your insurance starts paying your medical bills. Once you meet your annual deductible, your health plan will pay for covered medical and prescription costs for the rest of the year.
It is important to keep your health insurance up to date with no coverage gaps. If you are changing insurance plans, ensure that the new plan starts before the previous one ends. Additionally, call your insurer before any planned medical service to see if you need prior authorization.
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Private vs. public health insurance
Private and public health insurance differ in several ways, including coverage, cost, and access to treatment. Here is a detailed comparison between the two:
Private Health Insurance
Private health insurance provides coverage for cancer treatment, including diagnosis, scans, and various therapies. The specific coverage depends on the insurance provider and the level of cover chosen. Most private insurers cover biomarker testing, genetic counselling, and treatments that follow the standard clinical pathway. However, they may deny coverage for experimental or "off-label" treatments. Private insurance often offers quicker access to scans and treatments, and patients are more likely to be treated by the same consultant throughout their journey. This continuity can be reassuring and provide more opportunities to discuss symptoms.
Public Health Insurance
Public health insurance, such as the UK's NHS, also provides coverage for cancer treatment and assigns a specialist to work with the patient to determine the best course of treatment. The treatment provided is of high quality, but due to increasing pressure and demand, waiting times can be a problem. Over 100,000 patients in the UK have to wait longer than the stated two weeks to see cancer specialists.
Cost Comparison
Both private and public health insurance can incur out-of-pocket expenses for the insured. Private insurance typically involves premiums, copays, coinsurance, and deductibles. Copays are fixed amounts paid for each doctor's visit or medical care, while coinsurance is a percentage of the total cost of treatment paid by the patient. Deductibles refer to the patient paying for most healthcare costs until they have paid a certain amount, after which the insurance plan covers the remaining costs. Public health insurance may also involve out-of-pocket expenses, and it is important for patients to keep their insurance up to date with no coverage gaps to ensure continuous coverage during cancer treatment.
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Fertility preservation
Several states in the US have passed fertility preservation coverage laws, requiring insurers to cover certain fertility services for individuals who may experience "iatrogenic infertility," which is defined as infertility caused directly or indirectly by medical treatments such as surgery, chemotherapy, or radiation. These laws vary from state to state, with some states only covering fertility preservation (sperm or egg retrieval) and others offering additional services such as In Vitro Fertilization (IVF). For example, Arkansas law mandates that individual and group policies offering maternity benefits must include IVF coverage, while Texas state law requires group market insurers to offer IVF coverage as an option.
It is important to note that religious employers are often exempt from providing infertility treatment coverage if it conflicts with their beliefs and practices. Additionally, self-insured employers are generally exempt from these requirements. However, even in states without mandated coverage, some self-insured companies voluntarily offer insurance coverage for fertility preservation.
To assist cancer patients with fertility preservation, organizations like Save My Fertility provide pocket guides and resources to help patients preserve their fertility before, during, and after cancer treatment. The Oncofertility Consortium maintains a national database of healthcare providers specializing in fertility preservation for cancer patients, and organizations like Fertile Hope offer support and information to cancer patients and survivors navigating fertility preservation and insurance coverage.
While the cost of fertility preservation can be high, particularly without insurance coverage, some clinics offer significant cost reductions for patients in need of these procedures. Hospitals and adolescent and young adult (AYA) programs may also have charitable funds available to help with sperm banking and other preservation costs. Additionally, grants and discounts may be available through established financial assistance programs.
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Cancer tests, therapies, and treatments
Cancer is a complex disease that requires a range of tests, treatments, and therapies, which can be costly. It is very important to have a health insurance plan that covers cancer care. Most group health plans, as well as policies sold on the Health Insurance Marketplace and in the small group and individual markets, cover a set of essential health benefits, including cancer diagnosis and treatment. However, it is important to note that short-term, temporary, or catastrophic coverage health plans may not cover cancer treatment.
There are various cancer treatments available, each with its own costs and considerations. Common treatments include chemotherapy, radiation therapy, immunotherapy, and targeted therapy. Other treatments include hyperthermia, where body tissue is heated to kill cancer cells; photodynamic therapy, which uses light-activated drugs to kill cancer cells; and stem cell transplants, which restore blood-forming stem cells destroyed by chemotherapy or radiation therapy. Surgery is also an option, where a surgeon removes the cancer from the body.
When it comes to private medical insurance, most private insurers cover testing and treatment for patients who meet specific criteria. Biomarker testing, for example, is often covered by insurance, but with copays, coinsurance, and deductibles. Health insurers may deny coverage for treatments deemed experimental, "off-label", or differing from standard clinical treatment. It is important to understand your health insurance policy and its coverage for specific doctors, facilities, or treatments, as these can vary.
To manage the financial aspects of cancer treatment, it is crucial to stay up-to-date with insurance payments and avoid coverage gaps. Understanding the costs covered by insurance and out-of-pocket expenses is essential. Out-of-pocket maximums (OOP max) refer to the highest amount a person pays annually before insurance covers 100% of covered services. Additionally, keeping track of medical expenses, reviewing Explanation of Benefits (EOB), and seeking financial assistance or payment plans can help manage the financial burden of cancer treatment.
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Frequently asked questions
Most private insurers cover cancer treatment, diagnosis, and some biomarker testing for patients who meet specific criteria. However, it is important to note that short-term, temporary, or catastrophic coverage health plans may not cover cancer treatment.
A maximum out-of-pocket limit, or MOOP, is the most a patient has to pay directly for their healthcare expenses in a plan year. MOOPs are established in federal law and change annually. In 2022, the limit for an individual plan was $8,700, and $17,400 for a family plan.
Coinsurance is the percentage of each medical bill you pay even after you've paid the yearly deductible amount. For example, if a cancer drug costs $100 total per prescription and the patient's plan has a 20% co-insurance, the patient would pay $20 for the drug.
Copay, or co-payment, is a fixed amount a patient pays for a doctor's visit, prescription drug, or other types of medical care. For example, a cancer patient may pay $20 every time they see their primary care physician and $30 every time they see their oncologist.
If your finances are limited, ask your cancer care team for help from a caseworker, financial counsellor, or social worker. Organisations such as the American Cancer Society can also provide guidance and resources. You may also qualify for Medicaid, even if you haven't in the past.
