When dealing with a cancer diagnosis, there’s much to learn and many decisions to make. Trying to juggle it all can feel overwhelming. Our goal at Triage Cancer is to provide useful, accurate information about the legal and practical issues that can come with a cancer diagnosis. Armed with that information, people can better decide what to handle first and what to put off until later—the very definition of “triage.”
One of those issues is having the right health insurance plan, ensuring that it will cover the care that you need and not leave you with huge out-of-pocket costs and medical bills. Thanks to the Affordable Care Act (ACA), Americans have more options for health insurance and consumer protections than ever before. However, few of us are taught how to pick between health insurance options.
If you feel confused, you are not alone. Numerous studies show that a majority of Americans do not understand health insurance. Unsurprisingly, people may not be picking plans that work for them or using them to maximum potential.
Confusion about the health care system is compounded by the fact that things are frequently changing at the state and federal levels. Individuals often do not know where to turn for reliable, unbiased information.
Even if you already have a health care plan that works for you, it’s good to ensure it’s still the best option. Plans and pricing can change every year, so you may be able to find new coverage that is more affordable or better fits your needs (i.e., covering your providers or prescription drugs).
Here are some key steps to help you efficiently compare your health insurance options:
Understand the terms used in health insurance. Only four percent of Americans can define these terms, but knowing what they mean will help you get the coverage you need.
- Annual deductible: the fixed dollar amount you have to pay out-of-pocket each year, before your health insurance policy kicks in (e.g., $500, $5,000 or $0).
- Copayment: a fixed dollar amount you pay when you get medical care (e.g., a $10 copayment to visit the doctor)
- Co-insurance (cost-share): a percentage difference in what the insurance company pays for your medical expenses and what you pay for your medical expenses (e.g., 80 percent/20 percent)
- Out-of-pocket maximum: a fixed dollar amount that is the most that you will have to pay for your medical expenses out-of-pocket during the year
*Generally, your out-of-pocket maximum includes what you pay for your deductible, copayments and co-insurance. Once you reach your out-of-pocket maximum, your insurance pays a hundred percent of your medical expenses for the rest of the year. Most insurance companies only count expenses towards the out-of-pocket maximum that are from in-network providers. Also, some employer-sponsored plans may carve out expenses from the out-of-pocket maximum (e.g., copayments won’t count toward your out-of-pocket maximum). Finally, monthly premiums are never included in an out-of-pocket maximum.
Understand the protections that exist for health insurance consumers. For example:
- As of Jan. 1, 2014, you have the right to purchase individual health insurance even if you have a pre-existing medical condition such as cancer. You cannot be denied coverage and you cannot be charged more because of your cancer history.
- If you get a plan through your employer, the insurance company cannot impose an exclusion period when it will not cover care for your pre-existing conditions.
Investigate all of your health insurance options.
- It is important to understand all of your health insurance options for comparison in order to find the plan that works best for you. For example, if your employer offers you a health insurance plan but it has a very high deductible or does not cover your providers, then you may want to consider buying a plan in the State Health Insurance Marketplace.
Compare your health insurance options.
- There are three key things to look for when comparing your health insurance options: 1) the costs (e.g., monthly premium and out-of-pocket maximum); 2) provider coverage; and 3) inclusion of your prescriptions on the list of drugs covered by the plan (i.e., the formulary).
- When comparing plans, do the math. To calculate the true cost of a health insurance plan, multiply the monthly premium by 12, then add that number to the out-of-pocket maximum. The total is the most you will pay for the year to have the plan and use in-network, covered services.
Once you find a plan that works for you, you need to make sure that it is still the best option for you—every single year. Unfortunately, picking a health insurance plan is not a one-time chore, but it can get easier when you arm yourself with knowledge.
For more information about health insurance terms, picking a health insurance plan and using insurance, visit TriageCancer.org/HealthInsurance.