Cancer: Insurance

Insurance payment is a battle. While the fight against cancer takes all the courage you and your family circle can muster, don’t forget that the insurance and financial aspects of your treatment will also require time and energy. If possible, appoint someone to be captain of the reimbursement team — ideally the toughest, smartest member of your family or a friend — to take care of insurance issues when you do not feel well enough to do so yourself.

Be prepared for your cancer treatment:

• Understand your benefits as much as you possibly can. We realize that your plan is written in legal mumbo-jumbo, but your employee benefits person or insurance agent should explain anything you need to know. Find a patient advocacy organization for your disease, or try one of the drug company hotlines (chemotherapy and supportive care drugs). Do not go into treatment without the facts.
  
• Know what needs to be authorized by your insurance company . If you need referrals or authorizations and you (or your clinic or doctor’s office) do not obtain them, these services can be denied. Depending on your plan, this bill can fall right in your lap.
  
• Understand the expected treatment plan for your cancer . Cancer patients must depend on their providers (nurses and doctors) for the fight against cancer, but that does not mean you forfeit your right to be informed. Knowing your treatment plan means you can decide your costs.
  
• Keep your Primary Care Providor informed about what is going on with your treatment . You do not need to correspond with him or her yourself, but someone needs to make sure your cancer provider is doing so. You do not want them denying something after the fact. Send them your own patient health record from time to time, if you want to make sure this is being done.
  
• Understand all of your treatment alternatives . Cancer drugs can be expensive. Some policies pay for injectable drugs in all settings. On the other hand, you may have specialty pharmacy, home health, physician office, and hospital outpatient coverage for drugs like growth factors interferons, or some oral drugs. It would be in your best interest to find out which setting would cost you the least.
  
• Start your recordkeeping immediately. If you have your patient health record, you have your clinical information.
  
• Next, you need to keep records of the process. Assemble a file containing any paperwork you already have (such as bills or physician information), and keep a log of every telephone call you make to the plan. Always ask for the name and job title of the person you are talking to.
  

Special Benefits for Medicare Cancer Patients

The Medicare Cancer Coverage Act of 1993 - This act provides expanded coverage for more cancer drugs. This is the way it works: drugs are approved by the FDA for a certain diagnosis. But this act says that if the drugs are covered in compendia — a collection of medical publications — or in certain medical journals, cancer patients can get the drugs off-label (for diagnoses other than the FDA-specified diagnosis).

This benefits you because you can get a wider array of cancer drugs. The act also states that if a drug has an oral form and an injectable form, the oral form will be covered. In 1997, the act was updated to apply to oral and injectable antiemetics (anti nausea and vomiting medications) used in cancer treatment. There are also state cancer coverage laws, which govern other insurance that covers the same or more expanded off-label coverage as Medicare.

Clinical Trials - Cancer remains incurable for many patients. For that reason, you may want to research the options available through the experimental treatments tested in clinical trials. A clinical trial is a research study that answers specific questions about emerging therapies and determines new ways to improve cancer care or to enhance your quality of life. Medicare covers only trials that meet their criteria.

Your doctor should tell you whether the trial meets those criteria. If you have questions, call 1-800-MEDICARE (1-800-633-4227) — Medicare’s toll-free number for beneficiaries that offers information about benefits. Medicare does cover certain costs associated with trials, but unless you are in special colon cancer trials, they do not cover the drug. Here is how Medicare covers — and doesn’t cover — clinical trials.

Covered costs may include:

• Routine tests, procedures, and doctor visits
  
• Services or items usually associated with the experimental treatment, such as costs to administer investigational drugs
  
• Health care associated with being in a clinical trial, such as a test or hospitalization due to an unanticipated side effect or because the drug requires hospitalization
  Non-covered costs include:
  
• Investigational drugs, items, or services being tested in a trial. The exception to this is some trials for colorectal cancer.
  
• Items or services used solely for the data collection needs of the trial.
  
• Anything being provided free by the sponsor of the trial to the cancer clinic.
  
• Any coinsurance and deductibles.