Navigating Insurance and Medical Bills
Key Health Insurance Terms to Know
These common terms can help you better understand your coverage:
- Monthly premium: what you pay each month to have coverage – you pay these costs even if you never get medical care.
- Annual deductible: the amount you must pay out-of-pocket each year, before your health insurance policy kicks in. This fixed dollar amount could be $500 or $5,000. Some plans have a $0 deductible.
- Co-payment: a fixed dollar amount you pay when you get medical care. For example, when you visit the doctor’s office you might have a $20 co-payment; if you go to see a specialist, you might have a $40 co-payment. You usually pay your co-payment at the time you get care.
- Co-insurance (aka cost-share): a percentage difference in what the insurance company pays for your medical expenses and what you pay for your medical expenses. For example, if you have an 80/20 plan, the insurance company pays 80% of your medical expenses and you are responsible for 20% of your medical expenses, after paying your deductible.
- 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. Your out-of-pocket maximum will depend on your plan.
Learn more in Triage Cancer’s
Why the Out-Of-Pocket Maximum Matters
Generally, you reach your out-of-pocket maximum by paying your deductible, plus any co-payments that you make during the year, plus any co-insurance payments you make. So, it’s everything that you pay, except your monthly premiums. Once you reach your out-of-pocket maximum, your insurance pays 100% of your medical expenses for the rest of the year.
However, not all plans count the same out-of-pocket expenses toward this maximum. For example, some employer-sponsored plans may:
- Exclude deductible
- Exclude deductible and co-payments
- Separate medical and prescription drug costs
That’s why it’s important to understand not just the number but what counts toward it.
How to Compare Health Insurance Plans
Figuring out the most you will have to pay for a health insurance plan during the year is actually very simple: Multiply the monthly premium amount by 12 and add it to the plan’s annual out-of-pocket maximum.
For example, if you want to know the most you would pay for a plan that has a $300 monthly premium and an annual out-of-pocket maximum of $2,500, here’s how you do the math.
- Step 1: $300 (monthly premium) x 12 = $3,600
- Step 2: $3,600 (total amount of premium costs per year) + $2,500 (out-of-pocket max) = $6,100 total maximum cost for the year
Remember that cost isn’t the only consideration when picking a plan. Also check to make sure that your providers, facilities, and prescription drugs are all covered by any plan you choose.
To help you do the math to understand a plan’s costs and confirm it covers the things you need, use Triage Cancer’s Health Insurance Comparison Calculator & Worksheet.
Options When Losing Employer-Sponsored Health Insurance
COBRA
COBRA is a federal law that allows eligible employees to keep their existing employer-sponsored health insurance plan after experiencing a “qualifying event,” like leaving your job. If you choose COBRA, you will be responsible for up to 110% of the premiums. There are also state COBRA laws that you may have access to.
- Health Insurance Premium Assistance Program (HIPP): Some states offer a program that may help pay your COBRA premiums if you qualify for their State Medicaid program. This is an optional benefit, so it’s not available in every state.
- `To see if your state offers this program:
State Health Insurance Marketplace
Marketplace plans are standardized, have limited out-of-pocket maximums, and may provide financial assistance based on your income level.
Medicare or Medicaid
Depending on your income level, you may be eligible for Medicaid in your state. You may also qualify for Medicare if you are at least 65 years old or have been receiving Social Security Disability Insurance benefits for two years.
Another Group Plan
You may want to check your eligibility to join a spouse’s plan, or a parent’s plan if you are under the age of 26.
To learn more about health insurance options after losing employer-sponsored health insurance:
What to Do If Your Insurance Denies Coverage
If your insurance denies a claim, you have the right to appeal. The steps to appeal depend on the type of health insurance plan you have. If you have an individual or employer plan, you generally have access to an internal and external appeal
- Internal appeal: Ask your insurance company to reconsider
- External appeal: Request an independent third-party review
Patients are more likely to get the care that they need, if they use the appeals process. On average, 50% of the time, patients actually win their external appeal and receive coverage!
To learn more about the appeals process:
Stay Organized to Avoid Overpaying
You may receive multiple documents, including bills and Explanation of Benefits (EOBs).
Tip: Wait for your EOB before paying a bill to make sure the charges are correct.
To learn more about managing medical bills:
Tips to Lower Health Care Costs
You may be able to reduce costs by:
- Applying for hospital financial assistance programs, like Charity Care
- Using HSAs or FSAs
- Accessing Medicare Savings Programs and Extra Help
- Utilizing additional financial assistance programs
Learn more about managing costs:
You Don’t Have to Do This Alone
Navigating health insurance after a cancer diagnosis can be challenging, but free help is available.
Explore resources and get support:
