Laura Beilke, Esq:
So before I start today, I do just want to acknowledge that navigating health insurance is extremely difficult. They do not like to make it easy for us. It honestly feels like you're learning a whole new language when you're dealing with health insurance and in fact, 96% of Americans cannot define the most commonly used terms in health insurance policies. And because of that, it really makes sense that we have a hard time understanding our health insurance options, comparing those health insurance options. So hopefully after today you will feel a little bit more confident with everything. But before we get into a lot of today's topics, I do want to start with understanding the basics. So first I would like to go over some of the terms that are associated with the costs with health insurance. So first there is a premium, which is a fixed dollar amount that you have to pay each month just to have your health insurance.
So even if you never go and receive care, you will still be paying this monthly premium. But then there are terms associated with the costs when we do use our health insurance. So first there's the deductible, which is a fixed dollar amount that we have to pay first before our health insurance even kicks in and starts to pay for any of our medical expenses. So someone could have a $1,000 deductible or a $5,000 deductible. It's going to depend on the type of health insurance that you have. Then there is the copayment, and this is another fixed dollar amount that you have to pay when you go and receive certain types of care. And I like to think of it as an entrance fee when you're going and seeing your doctor because you're typically going to pay this first when you go to your doctor's office.
So maybe you're going and seeing your primary care physician and you have a $10 copayment or you're going and seeing specialists and have a $30 copayment. The amount is going to depend on the type of provider you're going and seeing as well as the type of health insurance policy that you have. Then there is the coinsurance or the cost share, and this is the difference between what the insurance company is going to pay for our medical expenses and what we are going to pay for our medical expenses. So let's say that we have an 80/20 plan. This means that the health insurance company is going to be responsible for 80% of our medical expenses and we are going to be responsible for 20% of our medical expenses. Then lastly, there is the out-of-pocket maximum, which we would argue is probably the most important thing anyone should know about their health insurance plan because in a worst case scenario, this is the most that you're going to be paying out of pocket for your medical care during the year.
So this is another fixed dollar amount, so someone could have a $5,000 out-of-pocket maximum or maybe even a $20,000 out-of-pocket maximum. Again, it's going to depend on the type of plan that you have. Because out-of-pocket maximums are so important and they can be difficult to understand, I do want to walk through an example of how an out-of-pocket maximum actually works. So I'd like you all to meet Dan. Dan has a health insurance plan that has a $2,000 deductible. It is an 80/20 plan and he has an $8,000 out-pocket maximum. Dan unfortunately has an emergency and he has to go to the hospital and he ends up spending a week in that hospital. And after he gets out of the hospital, he ends up with $102,000 hospital bill. How much of that bill is he actually going to pay? And I actually want to walk through the steps of how we get to that final number so we can get a good understanding of how that out-of-pocket maximum works.
So first, he's going to pay $2,000 for his deductible, which leaves $100,000 left of that bill, but because he has that 80/20 plan, he's going to be responsible for 20% of that $100,000 and now has $20,000 left. But remember, he has that $8,000 out-of-pocket maximum and since he's already paid $2,000 towards the bill, he only has $6,000 left to reach his full out-of-pocket maximum and his health insurance will kick in and pick up the rest of that bill. Now with this example, I am absolutely not suggesting that $8,000 is not a lot of money because it is a lot, but it's a lot less than that $20,000 if he didn't have an out-of-pocket maximum or even potentially that whole $102,000 hospital bill if he didn't have insurance at all.
If you would like to hear this example again or want to hear about those terms again, this is all a part of one of our animated videos on health insurance basics. So I'm not done with out-pocket maximums because the devil is in the details when it comes to these. Depending on the type of plan you have, you may have certain things carved out of what is actually counted towards reaching that out-of-pocket maximum. So first, if you have a family plan, you might have a separate individual out-of-pocket maximum as well as an out-of-pocket maximum for the family. If you're receiving your health insurance through the marketplace, that's actually probably the most protective for consumers because those plans are required to include any money paid towards your deductible, any co-payments that you've made, and any co-insurance for both medical care and drugs that you receive all have to be counted towards your out-of-pocket maximum.
Now with employer plans, they like to be a little creative with their out-of-pocket maximums as they will carve certain things out from actually being counted towards that final out-of-pocket maximum. So some will not include deductibles towards it, some may not include deductibles or co-payments, and they might also have a separate out-of-pocket maximum for medical care and the prescription drugs that you receive. So not only is it important to know what the actual dollar figure is for your out-of-pocket maximum, but it's also important to know where you are getting your health insurance from as well as what they're doing or what they're including towards the actual final out-of-pocket maximum.
So now that we have a good understanding of some of the basics around health insurance, where do we get our health insurance from? What are our options? And in the United States we actually get our health insurance from only three places. We're either getting it from the insurance company itself, we either are getting it from the government, and by that I mean Medicaid, Medicare, military veterans plans, but about 50% of Americans are still getting their health insurance from their employer. And at Triage Cancer, we really believe that it's extremely important for everyone to know all of their health insurance options so that they can do their best in figuring out what option is best for them. And because of that, we do have a lot of resources on health insurance, like quick guides, animated videos, recorded webinars that can help you with understanding all of the different health insurance options out there.
So with all those options, it may come a time where we actually have to compare options that are available to us. And so I'd like to walk through an exercise of how you should compare plan options and this exercise will apply to really any situation whether you are comparing two market plans or two marketplace plans with each other or if you're maybe comparing multiple employer sponsor plans or even with Medicare, whether it's like a Medicare Advantage plan or a prescription drug plan. So with this exercise, I do have three different plans that I pulled off of a marketplace to help us with this. So first there's a bronze plan with a $200 monthly premium, a $6,000 deductible and an $8,000 out-of-pocket maximum. Then we have the silver plan with a $275 monthly premium, a $2,500 deductible and a $6,000 out-of-pocket maximum. Then lastly, there is a platinum plan with a $400 monthly premium, a $0 deductible, and a $2,000 out-of-pocket maximum.
So just by looking at these three plans, can we actually tell what that plan is going to cost by the end of the year and which one is going to be the most cost-effective for us? And that is not a trick question, the answer is no. We actually have to do some math to actually compare these options. So how you do that is you take the monthly premium and you times it by 12 because that's going to be how much it's going to cost us to have the plan for the whole year. And then we're going to add to that the out-of-pocket maximum, because remember, in a worst-case scenario, this should be the most that we pay out-of-pocket for our medical expenses during the year. And in the context of cancer care, the likelihood is pretty high that we are going to be reaching that out-of-pocket maximum.
So if we do the math on all the plans, that bronze plan ends up costing $1,400 for the year, the silver, $9,300 for the year and the platinum, $6,800 for the year. So that platinum level plan actually ends up saving us almost $2,000 over the course of the year, even though I'm sure we all kind of got sticker shock when we saw a $400 monthly premium and we thought it was really expensive and we decided not even to consider that as an option. And I think that happens a lot because people are not putting that out-of-pocket maximum into consideration when they're looking and comparing their health insurance options. Unfortunately though, when we are comparing plan options, cost is not where we need to stop. We actually have some other things that we need to consider, like whether or not our providers are going to be covered by the plan as well as whether our prescription drugs are going to be covered by the plan.
And that might sound really obvious, but trust me, it is not obvious to everyone and we have calls with individuals all the time who say that they're really upset about their plan and it's not covering anything and they have all these medical bills. And after talking with them for a little bit, we figure out that they really didn't consider the network of coverage or the network of providers for their plan or the prescription drug coverage for their plan. So it is really important to keep that in mind when we're comparing our plan options as well as the costs that come with it. Well, we have a lot of resources to help us with picking health insurance plans. We have an animated video that goes over these considerations as well as the health insurance comparison worksheet that can actually help do the math for you when you're comparing the plans. And specifically with Medicare plans, we have a Medicare options comparison worksheet that can help you as well. All of these resources can be found on our website.
So now I'd like to go over some key ways to help lower costs when we are using our health insurance. So I mentioned that 50% of Americans are still getting their health insurance through their employer, but that begs the question, what happens if I need to take time off from work maybe because of a cancer diagnosis and I no longer have access to that employer sponsored plan? Well, there is a federal law called COBRA that allows eligible employees to keep their employer sponsored plan as if they were currently employed. And maybe some of you have heard of COBRA and kind of are thinking, "That's not going to be an option for me. It's really expensive." And it can be really expensive because you are now going to be responsible for 100% of the premiums. Another big pro about COBRA is the fact that everything you paid towards your deductible and everything you paid towards your out-of-pocket maximum is going to continue while you're on COBRA.
So maybe you're in a situation, it's middle of the year, you are already meeting your out-of-pocket maximum or you're very close to reaching your out-of-pocket maximum that may be more cost-effective to say on with the help of COBRA, instead of switching to, let's say a marketplace plan where you have to restart your deductible and restart your out-of-pocket maximum. So you know under COBRA that all you have to continue paying for the rest of the year is that monthly premium. There is also a program that we wish more people knew about, which is called the Health Insurance Premium Payment Program, and this is a program that is available at the state level through the state Medicaid program and it is an optional benefit for states, so not every state is going to have this as a benefit. But effectively what this program is that if you qualify for your state Medicaid program, but you have access to an employer sponsored plan like COBRA, the state will actually pay your COBRA premiums for you.
So effectively what is going to happen is if you want to enroll in this Health Insurance Premium Payment Program, your state is going to kind of run a cost analysis to see if it would be less expensive for them to cover all of your care under their Medicaid program or if it would be less expensive to just pay your employer sponsored premiums for you. And it's usually the case that it's cheaper for them to pay for your employer sponsored health insurance premiums instead. Again, this is an optional benefit for states, so it's not available in every state, but we do have information on what states do have this as an option on our charts of state laws as well as our state resources page. Sorry. Another place where people can get health insurance is through the Health Insurance Marketplace and the marketplace is basically an online shopping mall where the only thing that you can purchase is health insurance plans.
So if you go to the marketplace, this is where you can see plans that are available to you based off of your zip code and you can also use the marketplace to help see if you qualify for your state Medicaid program and I'll say with the marketplace, when we bring it up as an option, some people will tell us, "These plans are too expensive, we don't want to purchase a plan off the marketplace." However, these plans can actually be much more affordable than people think because there is more financial assistance to help with making the plans less expensive, whether it's helping lower the monthly premium or even helping with your out-of-pocket costs. In fact, four and five individuals who purchase plans off of the marketplace we're able to find plans that cost $10 or less a month in the premium. There is also financial assistance now for individuals who make over 400% of the federal poverty level.
I will say though, this 400% financial assistance is only going, or as of now we know it's only going to last until the end of 2025. We got this financial assistance through The Inflation reduction Act and it kind of sunset where it would end in 2025 unless Congress chose to extend it. Who knows if they will, but at least we know right now in 2025 we do have this financial assistance if you're looking for health insurance options. Medicare is a government health insurance that is available to individuals who are over the age of 65 or who have been receiving social security disability insurance for 24 months or who have end-stage renal disease or ALS. And there have been a lot of changes recently to Medicare in hopes of reducing the expense that comes with the Part D prescription drug costs. And I will say these changes have been kind of convoluted over the years.
Thankfully, in 2025 they did get a little bit easier. So one of the great things that came through the Inflation Reduction Act was a $2,000 out-of-pocket maximum for Part D drug costs. So this $2,000 out-of-pocket maximum is going to apply to anyone who is a Part D prescription drug plan as well as anyone who has a Medicare Advantage plan, which are the Part C plans, who have prescription drug coverage through it. It is not going to apply to any drugs that are covered under Part B of Medicare. There are some drugs that end up getting covered under Part B, and unfortunately those will not count towards the $2,000 out-of-pocket maximum. So in 2025 there is a $2,000 out-of-pocket maximum for Part D drug plans. We do expect that this amount is going to increase over the years and we do know that in 2026 that increase is going to be or it will now be $2,100 for next year. Another major change that came with the Inflation Reduction Act was the implementation of a program called the Medicare Prescription Payment plan.
So this is a program that allows you to spread out the cost of your prescription drugs over the year and it's important to remember though that this is about spreading out the costs and it's really not about savings. You are going to have the same cost for your prescription drugs whether or not you enroll in this plan, but this is a voluntary program that you can choose to enroll in or not enroll in, and you can choose to enroll in it at any point during the year and just like it is voluntary to enroll, you can also disenroll in it at any time, but if you do choose to disenroll, you are required to pay the remaining balance at that time. So effectively what is going to happen if you choose to want to enroll in this plan, you are going to contact your Part D plan and let them know that you want to enroll because they're the ones who are going to be running your Part D Medicare Prescription Payment Plan.
And once you are enrolled, instead of going to the pharmacist when you pick up your prescription drugs, you are not going to be paying your pharmacist anymore, so you'll have to pay nothing when you go to the pharmacist and instead your prescription drug plan is actually going to mail you the bill each month for your payment plan. So you will be receiving two bills a month from your drug plan, one for the monthly premium and then one for your Medicare Prescription Payment Plan.
We have also been seeing some situations with Medicare prescription drug plans where they are choosing to no longer cover certain drugs and they do this at any time during the plan year and unfortunately they are allowed to do this. They're allowed to change their formulary at any point and a formulary is basically a list of drugs that your prescription drug plan is going to cover. What we want people to know is that if you are in a situation where all of a sudden your prescription drug plan says that they are no longer going to cover your drug that you are taking, that doesn't mean that you can't get coverage for that drug. What you can do is you can submit what is called a Medicare prescription drug exception request. And this request is basically you asking your insurance company to cover this non-formulary drug as if it was on your formulary.
If you decide that this is something you want to do, you want to submit this request, it is really important to work with your healthcare team with this because they're going to submit a supporting statement that shows why this drug is medically necessary for you. Plus they will provide information about if there's a generic drug that's on the formulary and you've had bad side effects to that drug or it's not as effective as the brand name drug, your healthcare team will help provide evidence to show why you need to be taking this other drug and not the generic drug.
If you end up getting this exception request approved, that is great. That means that your drug will now be covered by your prescription plan. If for some reason it does end up getting denied, this is something that you can appeal and basically ask them to reconsider the denial and we will be talking about appeals in just a second. If this is something you are considering, I would recommend using a checklist that we have about how to make a Medicare prescription drug exception request. It can be really helpful just making sure everything is in order before you submit that request.
If someone is struggling around the costs associated with Medicare, there are a couple programs out there to help with this. One group of programs that can help are called the Medicare Savings Programs and there's actually four programs within those Medicare Savings Programs. Each one has different eligibility requirements and different benefits for them, but they will help with your Part A and your Part B. If you would like more information on these Medicare Savings Programs, we do have a quick guide to Medicare Savings Programs. Now, if someone is struggling with costs associated to their Part D prescription drug plans, there is something called the Low Income Subsidy or LIS or Extra Help and it can help with your premiums, your co-payments and your out-of-pocket maximums for prescription drugs. Some states also have pharmaceutical assistance programs to help with these costs. Not every state has them, but Medicare does have information available on the state programs as well as eligibility and benefits for these programs on their website.
So one thing that we think is incredibly beneficial for everyone to know is that if your insurance company tells you, "No, we are not going to be covering this claim." You do not have to take no as the final answer, us as consumers have two rights or two opportunities to appeal that decision. The first opportunity is called an internal appeal. And this is basically where we are going back to the insurance company and asking them to reconsider their decision. If, let's say, they still come back to you and saying, "No, we're not going to be covering this." Then you have a second opportunity called an external review. And this is where you're going to an independent third party that is completely separate from the insurance company and asking them to review the claim and see whether or not your insurance company should have covered it.
And what is great about the external review is that whatever they decide, that is binding on the insurance company. So if they say your insurance company should have covered it, they now have to cover it. And sometimes I feel bad talking about this, but it is an extremely important a process to know about, but I feel bad for the fact that I'm just asking you guys to do one more thing with health insurance and with medical care when you guys probably already have a ton of things on your plates that you have to worry about and you don't need one more thing to be put on top of that. But there is data out there that tells us when someone appeals, about 40 to 60% of those appeals are found in favor of the patient.
So that is telling us that the insurance company is getting it wrong about 50% of the time. One problem though is that we are barely ever appealing as a population. In fact, about 99.8% of denials never get appealed. And when we're talking about navigating health insurance, the costs that are associated with medical care, financial toxicity, this is an extremely underutilized tool that we have in our toolbox to help us out. Another difficult thing that comes with health insurance appeals is that it can be extremely overwhelming. There are probably going to be a lot of phone calls between you and the insurance company, potentially between you and your provider, even between the provider and the insurance company.
There's going to be a lot of paperwork, there could be deadlines that you have to worry about and it can be hard to stay organized with all of this. We do have a health insurance appeals tracking form to help with this, to help with notes. It can also be a great reminder about any deadlines that are coming up. This can also be a great time to delegate to friends and family members. I think this happens a lot where you have decided that you are going to share your diagnosis with friends and family and one of the first things that they say to you is, "How can I help?" Take them up on it, ask them for help during this time. It can be as simple as asking your friend to sit next to you while you're on speakerphone with the insurance company and they'll just be taking notes so you can just focus on the conversation with the insurance company. It really can be just as simple as that and it can be extremely helpful.
We have this sticky notes thing up here about don't do the sticky note method. I'm not a sticky note person, I'm a person that will just write in a notebook everything that's happening, whether it's work, social stuff or anything like that. And then five days later I need to go back and find those notes and try to decipher my handwriting. So we definitely don't recommend that, but any type of method that you think can just help you with this, it can be really helpful in overall to keeping and staying organized and keeping you through this health insurance appeals process. So this is kind of our appeals checklist of what to do when you are going through that health insurance appeals process. The first one, which I think is extremely helpful is just understanding why your claim was denied. It could be as simple as an administrative error that ended up leading to your insurance claim getting denied like a wrong CPT code was put in and that could actually be a really simple fix, like going to your healthcare provider and asking them to resubmit the claim.
But I think a lot of the times within the context of cancer care, people are getting denied because they say it's not medically necessary or it's experimental or investigational. And those are where it would be really important to work with your healthcare team to gather the evidence of why it is medically necessary or why it's not experimental or investigational. So they can really help with the gathering your evidence, making sure that you're submitting the necessary paperwork, especially paying attention to deadlines because there are some deadlines with this about when you need to submit your first appeal, how much time do you have until you can access the external appeal process? Staying organized, and especially during this process because it can be really time-consuming, don't give up with it.
So health insurance appeals I think is kind of a soapbox issue at Triage Cancer. We talk to people a lot about health insurance appeals, so we have a lot of resources on these. We just did a webinar about it earlier this week and a recording will be posted of that webinar. We have quick guides. It can be really helpful to use these resources. So even if you have done your best with picking the right health insurance plan for you, utilizing that appeals process, you are still likely to receive medical bills. And with the medical bills, you're also likely to receive a lot of correspondence. Just from the insurance company, you could receive three different pieces of mail.
One saying that they received the claim, one saying that they're processing the claim, and one called an explanation of benefits or an EOB. And this EOB will be a really good idea of how much you're actually going to owe your provider for your medical care. And these EOBs can actually be a little challenging to decipher so I do just want to show an example of one. Unfortunately, EOBs are going to look different depending on the insurance company that you have your health insurance through, but they should have this minimum level of information on it.
So the first telltale sign that this is an EOB that you're looking at and not a medical bill is that it will say, "This is not a bill." It'll also show some information about the policyholder and who the claim is for. It will show some sort of summary of the claim and then in the chart you'll see some more information about the services that were provided, like date of service, potentially a description, a CPT code, you'll see amount charged. And then in that last little bit of the column, it'll show how much you're likely to owe your provider. It will also tell you how much you've already paid to reach your deductible as well as your out-of-pocket maximum for an individual plan and also for a family if you have a family plan. Unfortunately, we are not done with the mail that you'll be receiving.
You're also going to be receiving a medical bill from your provider, whether it is your doctor, the hospital you received care at, maybe even a lab company. One of the problems with all of these is that first of all, they might not be sent in the same manner. So for example, you might receive some actually in the mail, some might be emailed to you, some might be only be able to be accessed through a patient portal that you have. They also most likely will not be sent in the same timeline of what we've been talking about them in. Providers are actually much faster at sending out the medical bill than the insurance company is at processing the claim. So it is really important to actually wait for your EOB before you pay for any medical bills because you don't want to be paying more out-of-pocket than you actually owe.
If you are waiting for your EOB, it would be really helpful to tell your medical provider that you are waiting to pay for it so they just don't think that you are not going to be paying it. This is also a great time to check for any mistakes, ask any questions like, why are you being billed for a certain service? This is also a great time to see if you need to appeal anything that has happened and utilize that appeals process. Another great thing to do is to see if maybe you qualify for what is called hospital charity care. And nonprofit hospitals are actually required to provide what is called charity care or financial assistance programs.
They are required to post their financial assistance policies online as well as in the hospital. However, with my own experience, those can sometimes be really difficult to find, which is why I just want to talk about another nonprofit called Dollar For. Their whole mission is to provide information around charity care and financial assistance programs so they can help identify which hospitals do have these financial assistance, the eligibility requirements for them, and they can also submit applications on your behalf. So this is also a great nonprofit to utilize during this whole process.
Now, if you are in a situation where you owe providers, we recommend trying to talk with them. We do recommend trying to talk with them before the due date comes and goes. And they maybe send any unpaid bills to collection agencies, but this is a great time to see if maybe they'd willing to work out a payment plan with you or you can negotiate a lower lump sum payment. We kind of like to think of the motto, "It doesn't hurt to try." With all of the paperwork that you're receiving, it can be hard to keep organized with everything, maybe even to know if you paid a bill or not or when a due date is coming up, so we have a resource called our medical bill tracker worksheet that can help keep track of all of your medical bills.
And how you use it is you actually just put in some short information about your health insurance plan, like your deductible, also what your out-of-pocket maximum is. And then as you start to receive medical bills, oops, sorry, as you start to receive medical bills, you can just put that information into that Excel sheet and then the top will actually calculate how much you have left to reach your deductible and how much you have left to reach your out-of-pocket maximum. So this can be another tool to help stay organized during everything.
So I've been talking a lot about out-of-pocket maximums and keeping track of it, and we say it's helpful to keep track of that out-of-pocket maximum, because you don't want to be in a situation where you're asked to pay more out-of-pocket than you actually have to. Insurance companies most likely are keeping track of how much you have left to reach your out-of-pocket maximum. However, you healthcare providers likely are not, they're not going to know whether or not you're close to reaching it or if you have reached it. And you could be in a situation where you've already met your out-of-pocket maximum and you shouldn't have any more out-of-pocket medical expenses during the year and you go and see your doctor and they ask you to pay a co-payment. And it would be great to be able to tell your provider that, "I've reached my out-of-pocket maximum. I have nothing more to pay." So sometimes I recommend even just keeping your most recent EOB that you have to let them know that you've reached it and you shouldn't be having to pay any more.
It's also really helpful to keep track of those medical bills, any prior authorizations you've had, any expenses you've had that are related to medical care, but maybe aren't exactly medical care, like travel and lodging, food expenses. These could all potentially be things that you could submit to a health savings account or a flexible spending account. Even if you don't have an HSA or an FSA a lot of these expenses can actually be tax-deductible at the end of the year. So it would be really important to keep track of all of these things so that you can get that deduction.
So if you'd like to hear me talk about this more and also hear my co-workers talk about this more as well as employment rights, disability benefits, estate planning, you could join us for our Triage Cancer conference. We have one upcoming on October 18th. We also do a webinar series on a lot of key topics within the cancer community. If you're unable to attend a live one, we do record all of them and the recordings are posted on our website. And then if you ever have questions and you want to speak one-on-one with one of our staff attorneys, you can always contact us through our legal and financial navigation program. We don't provide legal representation or legal advice, but we can help explain the law about a particular situation, help identify different options someone might have, and then also weigh the pros and cons of those options. And if you'd want to speak one-on-one with us, you can just go to triagecancer.org/gethelp. That is all I have for you. Thank you, everyone.
