A health insurance policy is a legal agreement where an insurer gives coverage for some or most of your medical care costs for a certain price. That price is called a premium.
If you work for a large company, the premium may be paid by your employer. If not, you may buy insurance on your own or through a group.
Health insurance can also be provided by the federal or state government, such as Medicare (for people over age 65) or Medicaid (for people with a low income).
The basic types of health insurance are:
Each type has pros and cons.
Fee-for-service plans give the most options in choosing health care providers and treatment centers.
However, these plans typically cost more and require more time doing paperwork.
In a fee-for-service plan, insurance will only reimburse part of medical costs (for example, you might pay 20 percent of the cost and the insurer pays 80 percent). The part paid by you is called the co-payment or co-insurance.
You may have to pay a deductible (a pre-set amount of your medical costs each year before the insurance payments begin).
No matter how much you pay in terms of the co-payment and deductible, the insurer makes the final decision on whether a certain procedure or cost will be reimbursed. You may have to get approval before the procedure is done. Sometimes, the insurer requests more information from the doctor.
In a fee-for-service plan, you may spend more time coordinating your medical care and filing for reimbursement than with other plans.
You must keep track of your own expenses, such as receipts for drugs and other medical costs. To get reimbursed for costs covered in your plan, you may have to fill out claim forms and send them to the insurer.
With managed care plans and health maintenance organizations (HMOs), you must use health care providers and medical centers that belong to the plan.
Your care is coordinated through your primary care provider, who controls all referrals to specialists.
Although you have fewer options for providers and treatment centers than with a fee-for-service plan, you pay less for medical care.
Most of a managed care plan's services are covered by the monthly or quarterly premiums. Often, there's a deductible. You usually have a co-payment for office visits and hospital stays.
With managed care plans, you rarely need to submit claims forms for reimbursement. So, you usually have less paperwork and less record-keeping than with a fee-for-service plan.
The preferred provider organization is a blend of fee-for-service and managed care plans.
In a preferred provider organization, you can make choices on a service-by-service basis. You can see a health care provider from within the plan’s network and have most of your medical expenses covered, or you can see a provider from outside the network and have fewer expenses covered.
Often, there’s a deductible for a preferred provider organization plan.
There's trade-off between cost and flexibility with each type of health insurance.
No option is right for everyone. Weighing the pros and cons can help you choose the plan that’s right for you.
If you don’t have health insurance, you can get coverage by:
As part of the Affordable Care Act, insurance companies can't limit coverage based on a pre-existing condition (such as breast cancer).
Although employers are the main source of group insurance coverage, organizations such as unions, professional associations, churches and civic groups may also offer insurance to their members.
These policies are set for a group of people rather than one person, so the premiums tend to be lower than individual insurance.
When you buy insurance as an individual, you usually pay higher premiums than through group insurance. However, in some cases, individual policies give more options that tailor benefits to your needs.
To find out more about buying individual insurance, contact an insurance agent or broker, your state insurance commissioner's office or your state health department.
Medicare is health insurance provided by the federal government to people who are 65 or older, on renal dialysis or permanently disabled.
Basic Medicare has 2 parts:
Medicare doesn’t provide comprehensive health care. However, as part of the Affordable Care Act, it covers a yearly wellness visit, screening mammograms and some other preventive services.
Medicare doesn’t directly pay for prescription drugs, although there are insurance companies that work with Medicare to help cover the costs of medications.
Medicare also doesn’t cover experimental treatments or services outside the U.S.
Medicare plans have co-payments and deductibles.
Medicare Part C (Medicare advantage plan) is run by private insurance companies (such as health maintenance organizations (HMOs) and preferred provider organizations) under contract with Medicare.
Medicare Part C includes Part A and Part B, but costs for services vary depending on the plan. Some plans offer prescription drug coverage.
Medicare Part D (Medicare prescription drug coverage) is run by private insurance companies under contract with Medicare. These plans help cover prescription drug costs.
For more information about Medicare, call the Medicare Hotline at 1-800-MEDICARE (800-633-4227) or visit www.medicare.gov.
A Medigap policy is private supplemental (extra) insurance that fills in “gaps” of Medicare coverage. It pays for some Medicare costs (like co-payments) and some services not covered by Medicare Part A and Part B.
If you have Medicare Part A and Part B (and don’t have a Medicare advantage plan), you can buy a Medigap policy.
There are many Medigap policies. The most basic plan covers items such as the co-payment for Medicare Part A hospital stays. Other Medigap plans cover items such as recovery at home and some prescription drugs costs.
For more information about Medicare or Medigap, call the Medicare Hotline at 1-800-MEDICARE (800-633-4227) or visit www.medicare.gov.
Medicaid provides health care to people who have a low-income. This program is run jointly by the federal government and state governments. So, benefits and eligibility (who can join) vary from state to state.
Your state may have a different name for Medicaid. For example, in Maine the program is called MaineHealth and in California, it’s called Medi-Cal.
You also may be eligible for Medicaid if you have very high medical expenses, even when your income level is too high to qualify.
For more information about Medicaid, call your state's toll-free hotline.
Insurance problems are stressful. If a claim is denied or if you change (or lose) your job during breast cancer treatment, there are things you can do. There are laws to protect you.
If a health insurance claim is denied, these steps may help resolve the problem:
If these steps fail to get payment for a claim you and your doctors believe is justified, a final option is to contact a lawyer.
National patient support organizations, such as the National Cancer Legal Services Network, can help find lawyers in each state who work on cancer-related insurance issues.
The Patient Advocate Foundation offers help resolving problems and help with insurance issues involving insurers, employers and creditors.
There are laws to protect you from losing health insurance coverage if you lose your job, change jobs or need to take time off during your breast cancer treatment. These are described below.
COBRA protects people who are covered by a group health insurance plan through an employer with 20 or more employees.
If you're not covered by COBRA (for example, if you work for a company with fewer than 20 employees), you may be able to switch your group coverage to an individual policy.
Although your premiums will likely increase, this may be a good short-term solution while you look for other options.
The Family and Medical Leave Act helps protect people from losing their jobs when they need to take time off for family and medical reasons. It allows you to take up to 12 weeks of unpaid leave within a 12-month period of time, without losing your job.
If you have a company group health plan, your employer must continue your health insurance coverage during the unpaid leave. If you are unable to work due to your treatment or the cancer itself, you are eligible. Any immediate family members (defined as a spouse, child or parent) who are caregivers are also eligible.
Having this job security allows you to take more time off once paid vacation or sick days are used up.
This law covers most people who have been working for their employer for at least 12 months.
As part of the Affordable Care Act, insurance companies can’t deny or limit coverage based on a pre-existing condition, such as breast cancer.
If get a new employer-based insurance plan or individual health insurance plan, the insurance company can’t deny or limit your coverage because you’ve been diagnosed with breast cancer.
SUSAN G. KOMEN® SUPPORT RESOURCES
1-877 GO KOMEN(1-877-465-6636)