Understanding Your Health Insurance

Health Insurance and Melanoma

While few people will have read and understand all of the fine print in their insurance policies, a basic understanding of the policy, what it covers, and what you may be responsible are critical to making informed decisions and minimizing frustrations later. When you are diagnosed with melanoma, understanding your insurance benefits is an important part of getting the care you need without a surprise bill.

How Do You Know What’s Covered?

Insurance plans vary in what and how they cover specific doctors, medical services, and even medications. One plan may cover 80% of your visit with your Primary Care Doctor while others may pay it all; one plan may include a specific medication in its approved formulary while others may not. It’s important to understand what may be covered under your plan and what you may be financially responsible for.

  • Summary of Benefits and Coverage: Every health insurance plan is required to have a an easy-to-understand summary about the plan’s benefits and coverage. If you don’t already have this document, you can request a copy by contacting your insurance company (the phone number will be on the back of your insurance card), logging into your insurer’s online portal, or by contacting your employer’s human resources department (if your coverage is provided by your employer).
  • Participating Providers: To maximize the value of your health insurance – and to minimize your out-of-pocket expenses – you’ll want to find and see doctors who participate in your insurance, commonly called ‘in-network providers.’ If you choose to see a doctor outside the network – or go to a hospital in a non-emergency situation – you may have to pay more than you would with an in-network provider. 
  • Formulary: Your insurance company will also have a list of covered medications – what they call a formulary. The formulary will include a list of medications and any conditions associated with accessing them. For example, you may need ‘Prior Authorization’ for some medications – something that your doctor can help you get. Don’t forget to recheck your formulary on an annual basis – sometimes they change!

Understanding What You Pay For:

When estimating what you may be financially responsible for, it’s important to remember that in addition to your monthly premium (which may be paid by you, your employer, or both), there are also several types of ‘out-of-pocket’ expenses that can dramatically impact your total cost of care.

  • Premiums: This is the amount you pay every month for your health insurance. Premiums may also be paid by your employer (if you get your coverage from work).

Deductible & Out-of-Pocket Costs: 

  • Deductible: Your deductible is the amount of money that you have to pay (on an annual basis) before your insurance plan will ‘kick in’ and start to cover a portion of expenses. If your plan has a $1,000 deductible, you will need to pay this amount before your benefits will start. Some preventive services, like physicals and some vaccines, are exempt from the deductible. 
  • Co-Insurance: After you meet your deductible and your insurance ‘kicks in,’ you may still be responsible for a portion of your health care costs – this is called co-insurance. You may be responsible for 10, 20, or up to 30% of the total cost of care – with your insurance plan covering the rest.
  • Co-Pay: A copayment, or copay, is the amount of money that you’ll pay each and every time you go to a doctor’s office, pick up medication, or get lab work done. Most insurance plans have different copays depending on the type of doctor, ‘tier’ of prescription, and number of lab tests that you need.
  • Out-Of-Pocket Max: This is the maximum that you will ever have to pay for covered services in any given year. After your costs of care exceed this amount, your insurance plan will pay for 100% of covered services. This does not include care provided ‘out-of-network.’

Many health insurers and hospitals offer some sort of case management or financial counseling that can help you navigate (and maximize) your benefits and better understand your policy. This may also be an area where a friend or loved one can help you.

What if Something Isn’t Covered?

If an insurance claim is denied, after getting over the shock or anxiety this will probably produce, contact the insurance company or your case manager to get more information about why the claim was denied. It may be due to a clerical error and be something that you can appeal. Sometimes, a denial can be overturned and some denials, while not due to clerical errors, can still be overturned with a justification from the doctor or further appeal. Be sure to keep records of all correspondence as it relates to the appeal process. This is undoubtably a frustrating process – but try to keep a cool head.

What if You Don’t Have Insurance?

If you don’t have health insurance, it may still be possible for you to sign up at Healthcare.gov. 

  • If you had insurance but lost your job within the last 60 days, you may be eligible for COBRA. COBRA is a government program that allows you to keep your health coverage after your employment ends (for up to 18 months) if you pay all of the premiums, including what your employer paid while you were working. Learn more about COBRA.
  • If you cannot afford insurance or cannot get it fast enough, inquire if there are programs to support people in your condition. If not, ask if they have information about community resources or other hospitals in your area who may be able to help. 

What Do You Pay for Clinical Trial Participation? 

The Federal Government requires that most health insurance plans cover routine care as part of participation in clinical trials if you are:

  • Eligible for the trial
  • The trial is approved – meaning the trial is testing ways to prevent, detect, or treat cancer or other life-threatening diseases AND is funded or approved by the federal government. All trials posted to Clinicaltrials.gov or available via MRA’s Clinical Trial Navigator are approved clinical trials. 

Health insurance plans are not required to pay for “research costs” associated with clinical trial participation. Examples of these types of costs include test or scans that are done specifically for research purposes. However, the trial sponsor usually covers these costs. Speak to the clinical trial staff if you have any questions about what you may be financially responsible for.

Be aware that if your health insurance does not cover out-of-network providers, the same will hold true as it relates to clinical trials implemented outside your network. If you choose to participate in a clinical trial, however, your insurance plan cannot limit your benefits or refuse to allow you to participate beyond what is already outlined in your plan. MRA encourages all patients to consider clinical trials, as clinical trials are the only way new treatments come to market, and sometimes the best treatment option for you may be found in a clinical trial. Learn more about melanoma clinical trials.

What Programs Exist to Help Defray Costs?

Pharmaceutical companies that make melanoma drugs have programs to help support patients with access to medication. Below are links to some of these programs.

Additional Resources:

Were you or a loved one just diagnosed with melanoma? We have the resources to help.

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