Managing Your Health Insurance and Medical Bills

Health insurance and medical bills can feel overwhelming when you or someone in your family has cancer. Understanding how your insurance works, how medical bills are processed, your rights, and where to get help can make it easier to manage these expenses.

Understanding your costs

Deductibles, copayments, and coinsurance are all costs you may have as part of your health insurance plan. Understanding these and other common health insurance terms can help you plan better for medical expenses during cancer care. Factors that affect your costs include:

• The types of treatment you need
• Where you are treated (for example, in a hospital or clinic)
• Your health insurance plan
• Whether your healthcare providers and treatments are in-network or out-of-network for your insurance

When is prior authorization needed?

Some treatments, tests, procedures, and prescription medicines require approval from your health insurance company before you get them. This is called prior authorization, pre-authorization, or prior auth.

Without getting prior authorization, you could be charged the full cost, with the insurer paying nothing. Your healthcare provider usually starts the prior authorization process.

Prior authorization is often needed for:

• Expensive treatments, procedures, or medicines
• Hospital stays or home health services
• Care provided by an out-of-network provider

Sometimes, the insurance company may need more information to support the use of certain treatments. You can also ask your cancer care team if there is another treatment that might work as well and that your insurance is more likely to approve.

Prescription medicine plans may also:

• Require you to try a different medicine first before they will approve the one your doctor prescribes.
• Limit how much of a medicine you can have at one time or how many refills you can have.

Prescription medicine plans often provide a formulary that lists the medicines they cover. If your healthcare provider thinks that the insurance plan’s preferred medicine wouldn’t work or wouldn’t be safe for you, you can appeal the decision.

What if I didn’t know I needed pre-approval?

In situations where you didn’t know your care needed pre-approval, you can appeal the insurance company’s decision to not cover the care or service.

If the appeal is denied, you can also contact the insurance regulators for help. If appeals and regulators do not help, you can try working with the healthcare provider or facility to get your bill lowered or set up a payment plan.

Understanding your medical bill

When you get your medical bill, review it to make sure all charges are correct and match your explanation of benefits (EOB) from your insurance company. The EOB shows you what care services you received, what your insurance paid, and what amount you still owe.

If something does not look right, contact your healthcare provider or insurance company to get clear information before paying your bill.

What happens if my bill is high?

If you’re having trouble paying for care, ask about payment plans, request assistance, and apply for programs that may offer help. Talking with the finance or billing office early about help can help you avoid your bill being sent to collections.

Knowing your patient rights

You have rights as a patient that help you make informed decisions about your health, safety, and protect your privacy. These protections are described in a patient bill of rights or as patient rights and responsibilities.

A number of organizations have a patient bill of rights. They are designed to help people:

• Take an active role in improving their health and creating an advance directive.
• Build stronger relationships with their healthcare providers.
• Know their rights when dealing with insurance companies and other groups about health coverage and payment for services.
• Know their rights to respectful care without discrimination and protection of their health information.

The American Hospital Association developed one of the first patient bills of rights, now called the Patient Care Partnership. It explains what people should be able to expect when they have to be in the hospital, including the quality of care, safety and privacy, and help with insurance claims.

The Affordable Care Act (ACA) also added protections for people with private health insurance.

These protections include:

• No yearly or lifetime limits on essential health services. Essential services include doctor visits, emergency services, hospitalization, preventive and wellness services, and prescriptions.
• The right for young adults to stay on their parent’s policy until they are 26 years old.
• Having clear information on what the health plan covers.
• The right to appeal insurance payment decisions of private health plans (called an internal appeal) and have an independent review (called an external review) if the company still denies the claim.
• Not losing your insurance coverage because of a mistake on your application or if you get sick.

There may be exceptions to some of these rights. Some plans, including grandfathered plans that were created before the law went into effect, may not follow all ACA rules . Be sure to review your plan for details and understand your coverage. You can also ask your employer or benefits administrator to find out whether your health plan must follow these rules.

Many states, insurance plans, and healthcare facilities have their own patient bill of rights or list of rights and responsibilities. Check with your insurance plan or healthcare provider to see if there’s one for you to review.

Learn more in Can I Get Health Insurance If I Have Cancer?

Need more information?

The following organizations may also offer helpful information. The American Cancer Society is not affiliated with or responsible for these resources:

US Department of Health & Human Services
Website: www.healthcare.gov

For the most up-to-date information on healthcare and insurance laws and how they might affect you.

US Department of Health and Human Services
Website: www.healthcare.gov/how-does-the-health-care-law-protect-me

Explains patient rights with regard to health insurance under the Affordable Care Act.

National Association of Insurance Commissioners
Toll-free number: 1-866-470-6242
Website: content.naic.org

Offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company.

Patient Advocate Foundation (PAF)
Toll-free number: 1-800-532-5274
Website: www.patientadvocate.org

Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. For cancer patients in treatment or less than 2 years out of treatment.

Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114
Website: www.medicarerights.org

This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They can also help you apply for programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if your Medicare prescription drug plan denies coverage for drugs you need.

American Hospital Association
Toll-free number: 1-800-242-2626 (this is the customer service/publication order line)
Website: www.aha.org

AHA’s Patient Care Partnership brochure teaches patients about rights and responsibilities related to their hospital stay. The brochure is sold in bulk orders only, and there’s a fee for non-members. You can read it online for free (in English, Arabic, Chinese, Russian, Spanish, Tagalog, and Vietnamese) at www.aha.org/aha/issues/Communicating-With-Patients/pt-care-partnership.html.

National Library of Medicine
Website: www.nlm.nih.gov/medlineplus/patientrights.html

Has information on patient rights, along with many links to other sources of related information.

Triage Cancer
Phone number: 424-258-4628
Website: www.triagecancer.org

Provides free education and resources related to health insurance, medical bills, employment, and disability.