Cancer & Insurance: 3 Tips for Buying on the Health Benefit Exchange

Vice President, Managed Care
Thursday, October 1, 2015 - 12:55pm

Buying health insurance on the Health Benefit Exchange is a daunting task that can be fraught with pitfalls, especially if you or a family member has cancer.  There are plenty of helpful resources however (see below), and if you tread carefully and thoughtfully, you can make choices that provide the best coverage for your medical and prescription drug needs.  The open enrollment period is November 15, 2015 to January 31, 2016. 

Here are some suggestions and cautions that you might keep in mind if you’re shopping for a policy to cover someone with cancer:

1.  Does the plan cover your doctors, hospitals, and clinics?

Find out if they are included in the plan. Plans can change the doctors, hospitals, and clinics they cover.  Call each of your providers to make sure they are in network with the plan you are considering.  If your doctors, hospitals, or clinics are not covered under the plan for the period of your policy, you will likely have to pay more to see them when they become out of network. Some plans will not cover any of the costs of providers who are not in the plan network.  It’s important to do your homework on who is in-network with any of the plans you may buy.  The American Cancer Society provides a very helpful worksheet for comparing the costs of alternate plans.  

While the Affordable Care Act prevents insurers from imposing annual and lifetime monetary limits on benefits, plans may still have certain limits, such as on the number of physician visits a patient may have in a year. IV chemo is usually covered as a medical visit.  Beware of visit limits, especially if your care requires frequent doctor visits.

Also keep in mind that a high-deductible plan will require you to pay 100 percent of all medical costs out of pocket until you satisfy your deductible. There may even be a higher deductible for out-of-network care. This can be very burdensome for those with already tight finances. While such a plan will look attractive because of its lower premium, you must consider your ability to pay the higher out-of-pocket costs.   

2.  How does the plan cover prescription drug costs?

Some plans charge a co-pay, which is a flat rate the patient pays per prescription. Other plans charge a co-insurance, which is a percent of the total cost of the drug. This can be especially expensive for cancer patients who undergo multiple services such as Chemotherapy and Radiation Therapy for treatment. For cancer drugs, a co-pay will almost always be less expensive than a co-insurance.

Plans usually divide the drugs they cover, known as the “formulary”, into tiers or categories. The higher the tier a drug is placed in, the more you will pay for the drug. Cancer drugs are often in the highest tier of a plan. You may want to compare each formulary to see where your drugs fall within the plan tiers.

You also want to find out about a plan’s appeals process in case there are changes in the coverage of a particular drug you need, or if your doctor prescribes a drug that is not on the plan’s formulary. This is particularly important for someone living with cancer who may be taking several very expensive medications. If this information is not on the insurance company’s public website, you can call the insurer for details.  

3. Will Step Therapy limit your access to medication?

Many insurers are building “step therapy” or “fail first” rules into healthcare policies. They require patients to try less expensive medications before providing coverage for medications the physician would prefer to prescribe. Only after the initial medication proves ineffective for the patient can treatment progress to other more costly therapies. Physicians and patient advocates are concerned that step therapy delays access to treatments offering the greatest medical benefit, and therefore are not in a patient’s best interest. Many states have passed laws that allow physicians to appeal and/or override these policies. In New York, the bill (# A03142) that allows overriding step therapy is pending. If your state has not enacted this kind of law, you may want to call the insurance company to find out about its step therapy policies.

Helpful Resources
Health Insurance Marketplace basics or call 1-800-318-2596 (open 24/7)
An overview of Health Insurance Marketplaces (Patient Advocate Foundation, the Patient Action Council and the National Patient Advocate Foundation)
Information on enrolling in a NY health plan or call 1-855-355-5777
Assistance in enrolling in a NY Health Plan (New York Public Library)
Health Insurance Marketplace Calculator