Breast Cancer and Health Insurance: 5 Things You Should Know

breast cancer awareness month

Cancer is never straightforward or simple… especially when it comes to insurance. That’s why, in honor of Breast Cancer Awareness Month, we want to empower breast cancer patients with better knowledge about how to buy, use, and afford their health plans.

Here are the top 5 things we want all breast cancer patients to know.

1. Time to Enroll in Health Insurance? Be Sure to Shop Smart

Unless you have a qualifying event, you can only enroll in health insurance during one time of year: the Open Enrollment Period (usually around November–December, depending on your state). It’s important to use this time each year to review your insurance and ensure you’re on the most cost-effective plan. Here are a few shopping tips:

  • Look for an option in a higher metal tier (like gold or platinum) and with a low deductible ($1,000 or less). These plans may seem expensive each month, but they can actually save you thousands in the long run. That’s because these plans offer more coverage and are usually more flexible about where you get your care. Your insurer will be willing to pay more for each treatment, hospital stay, and prescription, lowering your out-of-pocket costs compared to a less expensive plan.

  • Check to see if you are eligible for a subsidy. Most people qualify for assistance with their health plan costs, making plans with extensive coverage more affordable.

  • Consider enrolling in your own plan. If you’re not subsidy eligible (or you opt not to use one), you can get a plan with more extensive coverage, and let your spouse and/or family members enroll in a different, more affordable option. This can reduce your family’s total monthly premium costs.

  • Ready to choose? Have a checklist ready. All health plans have their own agreed-upon networks of providers and prescriptions. You can call any insurance company to learn if (and to what extent) their networks will cover your care needs. Make a list of your most common medical costs so you know what specifics to ask. This list should include things like:

    • Your primary care doctor

    • Your specialists (including your oncologists)

    • Your hospital

    • Other care facilities you prefer (labs, imaging centers, infusion centers)

    • Your medications (including prescriptions and chemotherapy)

Want more tips on shopping for health insurance? Our Open Enrollment Guide can help you better understand complicated terms, make sure your care is in-network, and more.

2. All Health Plans Come with Free Preventive Care

No matter which plan you end up choosing, all Affordable Care Act-approved plans come with certain services that help you prevent and manage breast cancer. These services are 100 percent covered, meaning they won’t cost you a dime, and include:

  • Breast cancer genetic test counseling for women with a family history of breast cancer. If you have not been diagnosed with breast cancer, your provider can use this genetic testing to lower your risk for developing it later on.

  • Mammography screenings for women over 40 years old.

  • Annual well-woman visits available to all women, including PAP smears, physicals, and counseling with your provider to review your health status.

3. Out-of-pocket Costs are Something to Watch Out For

Did you know that the average cost for a patient’s first year of breast cancer treatment is $23,078? One important way to lower costs is to stay in-network as often as possible. This means using lab work and imaging facilities, hospitals, and providers who accept your insurance. Keep in mind that not all providers at a certain location will be in-network, so it’s always a good idea to confirm before receiving treatment.

All the same, it’s still common for cancer patients to get hit with out-of-pocket costs. According to one study, the most common out-of-pocket expenses for breast cancer patients are:

  • Devices (e.g. wigs)

  • Alternative medicine

  • Drugs

If you find that you are denied coverage for certain treatments, there are ways to appeal and work with your insurance company. More on that in the next tip!

4. Get Ready to Work with Your Health Insurance Company

You’re going to be using your insurance often, which means you’ll want to know who to talk to, which questions to ask, and how to get the support you need. We have a few suggestions to get you started.

  • Save a copy of your plan’s Summary of Benefits and Coverage (SBC). An SBC provides your plan basics – like how much doctor visits will cost – and is a good starting point when determining which care you would like to receive. You can request this from your insurance company, or simply Google “[Your plan name] SBC.”

  • Get to know your insurance company’s website. Most insurers have tools that help you find in-network doctors, locate pharmacies, estimate costs, pay bills, and track your annual health care spending. Spend some time setting up your account and locating these tools so you can put them to work!

  • Ask for a case manager. Your insurer can often assign a single person to help you coordinate your many medical claims. Case managers are good resources to ask questions such as:

    • Will I be covered for out-of-network care?

    • Do I need a referral to see a specialist?

    • Is this doctor or prescription covered by my plan?

    • Do I need pre-approval for certain treatments?

  • Keep good records. Paperwork may seem old-fashioned, but it can come in handy (e.g. if you’re ever denied coverage). Make sure you file away:

    • Medical claims from your insurance company

    • Receipts for your medical expenses

    • Descriptions of any conversations with the insurance company, including the dates, times, and names of representatives with whom you spoke

    • Descriptions of conversations with your providers, including the dates and times

    • Copies of letters you send to your insurance company

  • Be prepared to stick up for yourself. If you’re denied coverage, you have 80 days to file an appeal. This asks your insurance company to reconsider their denial so you aren’t stuck footing the bill. Read our tips on how to file a strong appeal here.

5. Financial Resources Might Be Available If You Need Them

If you do not have health insurance or are struggling to afford your bills, there are a few resources you can turn to for support. These include:

  • Medicaid: A free, government-run insurance program for low-income people. To see if you qualify, visit their website here.  

  • The Susan G. Komen Foundation: This organization supports local breast cancer treatment, education, and screening programs. They may be able to help you track down local financial assistance and care if you’re uninsured.

  • Local pharmacy programs: These statewide patient assistance programs can help you get free or low-cost medications.

  • Cancer Care: This organization connects patients with oncology social workers who help you find financial support. The program itself offers limited assistance for costs like child care, home care, anti-nausea medication, and transportation.

  • The Pink Fund: This nonprofit covers 90 days of non-medical, cost-of-living expenses to help you get back on your feet after treatment.

Have specific questions about health insurance that we didn’t cover? Need help picking a plan? Feel free to contact our award-winning team of specialists anytime.

Aly KellerComment