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Home > Understanding Breast Cancer > Treatment > Insurance & Financial Issues > Comparing Health Insurance Plans

  


Comparing Health Insurance Plans

 

When you review a health insurance policy, or compare one plan to another, consider:

  • Medical coverage
  • Costs

Review each policy to see:

  • Which services are covered
  • Limits on services
  • Types of services that are excluded (not covered)
  • Steps for getting services (especially who must approve different services)
  • Limits related to pre-existing conditions (see more below)

For help in comparing policies, talk to a licensed insurance agent or your employer's benefits manager.

Pre-existing conditions

As part of the Affordable Care Act (health care reform), insurance companies will no longer be able to apply limits on pre-existing conditions in 2014. Until that time, the law provides for a Pre-Existing Condition Insurance Plan for people who have been uninsured for six months or more due to a pre-existing condition. These plans are run by state governments and thus, options vary by state. Learn more about Pre-Existing Condition Insurance Plans.

Coverage of medical services

As you compare policies, look at coverage for these basic medical services:

  • Inpatient hospital services
  • Outpatient surgery
  • Physician in-hospital visits
  • Physician office visits
  • Skilled nursing care
  • Medical tests and X-rays
  • Prescription drugs
  • Durable medical equipment (prosthetics, etc.)
  • Mental health care
  • Home health care visits
  • Rehabilitation
  • Physical therapy
  • Hospice care  
  • Chiropractic care
  • Preventive care and checkups
  • Second opinions  
  • Integrative and complementary therapies  
  • Other services that are important to you and your family

Coverage of cancer-related services

Health insurance policies should cover standard care for breast cancer. Treatment guidelines based on the latest research help ensure quality standard of care. The American Society of Clinical Oncology (ASCO) and National Comprehensive Care Network (NCCN) regularly update and post breast cancer treatment guidelines online.   

Polices should cover:  

  • All breast cancer-related drugs and therapies that are FDA-approved and given by a health care provider.
  • New procedures, drugs and techniques that are established in the scientific literature as being effective in treating breast cancer and thus, have become standard treatments. Insurance policies should state how they resolve questions on whether a new procedure or drug is a standard therapy. (For example, they may contact a state association of cancer specialists to review the therapy.)
  • Drugs used in combination with other drugs. (Drug combinations are common in standard breast cancer treatments.)

Other breast cancer-related features that should be reviewed in each insurance policy include:

  • Payment for drugs listed as "Group C" agents by the National Cancer Institute (NCI) or as "Treatment IND" by the Food and Drug Administration (FDA). These drugs have shown clinical benefit in treating cancer, but have not yet been FDA-approved. NCI and FDA reviewers believe these drugs show more promise than others.
  • Payment for standard patient care costs for people enrolled in FDA-approved clinical trials or National Institutes of Health-sponsored trials. Clinical trials provide new treatments to people with cancer, but they may not cover costs such as diagnostic tests, hospital stays and physician office visits. A policy that offers this coverage, even at a higher premium, could be worthwhile.

Provisions in the Affordable Care Act (health care reform) set minimum benefits that health insurance plans must cover. The law also includes provisions to protect people from excessive out-of-pocket health care costs. Some provisions are in effect now and others will phase in over the next few years. Learn more about the Affordable Care Act.

Cost

As you compare insurance policies, look at these costs:

  • Monthly, quarterly or yearly premiums   
  • Discounts for good health or healthy behavior (such as being a non-smoker)
  • Yearly deductible (per person or per family)
  • Co-insurance or co-payments for each service (such as, office visits, inpatient hospital care, emergency room visits and prescription drugs)

Other factors to consider

Other health insurance plan issues to consider include:

  • Whether the policy is guaranteed renewable (that is, the insurance company must renew your policy for a certain amount of time, even if your health condition changes)
  • The insurance company's rating (All insurance companies are rated by A.M. Best and Company, whose directory can be found online or in the reference section of a public library. Look for a rating of A or A+.).

Updated 12/13/13

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