The fine print

Most insurance companies refuse to cover therapies they consider experimental or investigational, such as immunotherapy and stem cell transplant for some cancers.

If an investigational therapy is your best treatment choice, ask your doctor or hospital social worker to serve as your advocate and help you appeal your claim:

Ask your doctor to send the insurer the research that shows how promising the new treatment is.
See if the pharmaceutical company that developed the treatment will lobby on your behalf.
Find out if the treatment is part of a clinical trial. If so, some of your costs may be covered.
If your appeal is turned down, try to negotiate a lower out-of-pocket cost with your facility.

To Learn More

To file a complaint against your insurer, visit the National Association of Insurance Commissioners website: www.naic.org.

The Patient Advocate Foundation can help you resolve disputes with insurers: www.patient advocate.org

Paying for treatment

Persistence and good planning can surmount financial challenges.

When you have cancer, managing the financial costs may seem almost as overwhelming as fighting the physical and emotional battles. It can be an enormous help to delegate the day-to-day responsibility for dealing with your insurers to a family member or friend.

What’s your plan?

If you have group or individual health insurance, many of your initial medical expenses may be covered by your plan.

However, you are likely to face large bills for prescription drugs or treatments that your insurer may not cover in full or at all.

In addition, health insurance policies frequently cap the total amount they will pay for claims during your lifetime. While these limits are high, they may not be high enough to cover the care you need, especially if the cancer requires complex or long-term treatment. One solution may be to purchase a catastrophic insurance policy that begins to pay if you reach your basic plan’s cap. When they’re offered as an employee benefit, these policies tend to be reasonably priced and are available to all eligible employees.

If you’re looking for catastrophic coverage as an individual, you’ll find it can be very expensive. One solution may be to investigate group coverage that’s available through professional, fraternal, or other associations to which you belong.

Moving on

Many employers offer more than one plan, so you may be able to switch to a more comprehensive alternative at the next enrollment period. If you’re married, and your spouse has insurance through an employer, check to see if that plan is more generous.

If your medical treatment coverage does not meet your needs, your spouse may consider switching jobs if they can find one that provides better insurance. If you’re covered under one employer’s plan, the law says you and your dependents are eligible for coverage under a new employer’s plan even with a previously existing health problem, as long as employment terms are met.

If your illness means you must leave your job, you can usually continue coverage through the same insurer, under COBRA. However, you must pay the total premium plus an administrative fee.

You should also investigate whether your state offers a high-risk comprehensive health insurance plan, or CHIP. If you’ve had continuous group coverage and enroll in the state plan within 63 days after it ends, there’s no waiting period for coverage of pre-existing conditions. However, state plans vary in cost and coverage caps.

Backup arangements

If you don’t qualify for, or can’t afford, commercial insurance, you may be eligible for public health insurance. Go to your local social services agency or other community organization for help.

Medicare. This federally subsidized program covers people 65 and older or those who have been permanently disabled. Because metastatic cancer qualifies as a permanent disability, you may be eligible, although there is a two-year qualifying period. Not all medical providers accept Medicare, so check with your oncologist or facility.

Medicaid. You may qualify for subsidized healthcare through Medicaid, a government program for low-income families. You are likely to be limited in your choice of doctors, facilities, and types of treatment.

Veterans Affairs. The VA covers veterans who served on active duty, and sometimes their families, in their own facilities. You can contact your local VA office to find out if you’re eligible.

Never give up

If an insurance claim is turned down, you should always appeal.

Keep records. Make copies of all of your insurance claims. Keep your original insurance policy and any addendums. Keep a log of all phone conversations and correspondence with your doctors and insurers. Never submit original documents.

Stay involved. Many claims are denied because of missing or incorrect documentation, or because a clerk doesn’t recognize a code your provider has used. The insurer may not request the missing information unless you ask about the status of your claim.

Be prompt. Some insurers have deadlines for filing an appeal. Act promptly and enlist the help of your doctor or nurse if medical information is required.

Contact your state insurance commissioner. Each state has an office dedicated to monitoring the insurance industry and resolving disputes. Insurers with a pattern of denying claims may be prosecuted.