When evaluating a health insurance policy, or comparing one policy to another, you should consider coverage of medical services and costs. Each policy should be reviewed to see which services are covered, the limits on services, the types of services that are excluded and the restrictions that apply to pre-existing conditions. It is also important to review each policy’s procedures for getting services, especially who must approve various services. For help in evaluating policies, you can consult a licensed insurance agent or your employer's benefits manager.
Coverage of General Medical Services
You should evaluate coverage for the following 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
- Preventive care and checkups
- Second opinions
- Complementary therapies
- Other services that are important to you and your family
Coverage of Cancer-Related Services
Insurance policies should meet the following minimum standards for cancer benefits, according to the Association of Community Cancer Centers, Oncology Nursing Society and National Coalition for Cancer Survivorship.
Coverage for all cancer-related drugs and therapies that are FDA-approved and chosen by a health care provider. This includes coverage of all FDA-approved drugs for all conditions that are listed in the package insert, drug label, U.S. Pharmacopoeia Drug Information Guide for the Health Care Professional or American Hospital Formulary Service Drug Information.
Coverage for new procedures, drugs and technologies that are established in the scientific literature as being effective in the treatment of cancer and have thus become standard therapies. Insurance policies should state how they resolve questions concerning whether or not a new procedure or drug is established as a standard therapy. For example, they may contact a state association of cancer specialists to review the therapy.
Coverage for drugs that are used in combination with other drugs. Because drug combinations are common in standard cancer treatments, health insurance policies should cover drugs that are used this way.
Other cancer-specific 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 are drugs that have shown clinical benefit in the treatment of cancer, but have not yet been fully approved by the FDA. NCI and FDA reviewers believe that these drugs show more promise than other therapies and should thus be covered.
- Coverage of standard patient care costs for people enrolled in FDA-approved clinical trials or NIH-sponsored trials. Clinical research trials provide experimental therapies to people with cancer. Often, however, costs such as diagnostic tests, hospital stays and physician office visits are not covered. A policy that provides this coverage, even at a higher premium, could be worthwhile.
Cost
In terms of costs, the main categories to compare are:
- Monthly, quarterly or annual premiums.
- Discounts for good health or healthy behavior (such as being a non-smoker).
- Annual deductible (per person or per family).
- Co-insurance or co-payments for each situation (e.g., office visit, inpatient hospital care, emergency room visits and prescription drug coverage).
Other Factors to Consider
Other aspects of a health insurance plan that should be considered 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 annual directory can be found online or in the reference section of public libraries. Look for a rating of A or A+.
Updated 02/02/09
