What Does Health Insurance for Mesothelioma Patients Cover?
In general, health insurance covers the vast majority of cancer treatment costs. But the amount you have to pay out of pocket depends on what type of treatments you receive, where you receive them and what type of health insurance you have.
A 2017 American Cancer Society report estimated how much patients with different types of coverage have to pay for one year of advanced lung cancer treatment, which is comparable to pleural mesothelioma treatment.
In the U.S., employer-sponsored health insurance usually provides more affordable coverage. This is because buying health insurance as a group allows a company’s workforce to get better terms.
However, most mesothelioma patients are retired by the time they are diagnosed, and younger patients may have to leave their jobs when they begin treatment.
Private Individual Insurance
Americans with individual health insurance policies face high costs for health care. Because they are not buying health insurance as a group, they may have to pay higher monthly premiums.
The government subsidizes health insurance premiums for low-income Americans. Even then, though, individual health insurance plans typically shift costs to patients through higher deductibles and more expensive copays or coinsurance rates.
Medicare, Medicaid and VA Health Care
Most mesothelioma patients are covered by Medicare or Medicaid, which are the largest federally funded public health care programs in America. Many mesothelioma patients are also eligible for VA health care benefits.
Medicare typically covers those over the age of 65 who have paid into the system throughout their working lives. There are four main parts in Medicare that determine what is included in each person’s coverage.
- Part A: Covers inpatient care in hospitals and nursing, hospice or home facilities.
- Part B: Costs an additional premium each month and includes doctor visits, laboratory costs, medical equipment and ambulance care.
- Part C (Medicare Advantage): Purchased from a private insurance company as an alternative to original Medicare. Includes benefits of parts A, B and usually D.
- Part D: Costs an additional premium each month and helps pay for prescription drugs.
A Medigap policy is a private health insurance plan that supplements Medicare. Medigap policies often have expensive premiums, but they can close the gap between what Medicare covers and what a patient needs.
Medicaid is designed to cover the cost of medical care for those with low income. Not all health care providers accept it, and benefits can vary from state to state, but it often covers mesothelioma treatment.
Veterans with mesothelioma are often eligible for low-cost or free cancer treatment from the U.S. Veterans Health Administration. This national network includes prominent mesothelioma specialists in Los Angeles, Boston, Miami and Houston.
The best time for financial planning is at the beginning of your mesothelioma treatment. Ask an insurance company representative, hospital social worker or patient advocate for help understanding the following terms and what they mean for your situation.
- Deductible: How much you have to pay out-of-pocket every year before your insurance coverage kicks in.
- Copay and Coinsurance: How much you have to pay even when your insurance is covering you. A copay is a flat fee per service, and coinsurance means you have to pay a percentage of each medical bill.
- Premium: Your monthly payment to stay covered by health insurance. Generally, a higher premium means a lower deductible and lower copays/coinsurance.
- In-Network vs. Out-of-Network: Health insurance plans usually specify certain doctors, hospitals and pharmacies where copays and coinsurance are cheaper. This is called their health insurance network.
- Because asbestos-related cancer is rare, seeing a mesothelioma doctor may require you to go outside your plan’s network.
- Out-of-Pocket Maximum: Once you have paid the maximum out of pocket, the law requires most insurance plans to cover your medical bills at 100 percent for the rest of the year. For 2019, the maximums were set at $7,900 for individual plans and $15,800 for family plans.
- Affordable Care Act (ACA): This 2010 law enacted many reforms that directly benefit mesothelioma patients today.
The ACA sets minimum health insurance standards that include cancer screenings, cancer treatment and follow-up care. It forbids insurance plans from having lifetime or annual limits for how much they provide for cancer treatment.
Most important, the ACA prohibits insurance companies from dropping patients with serious diseases or excluding patients with pre-existing conditions such as cancer.
The American health care system still presents many serious challenges, however.
Balance Billing: When a health care provider sends a bill to your insurance, but your insurance decides not to pay all of it, you could be billed for the remaining balance. This often happens when patients receive care from an out-of-network provider without realizing it.
Further, when patients receive a treatment their insurance company refuses to cover, the company could deny the health insurance claim completely.
What If My Health Insurance Claim Is Denied?
If your health insurance company denies a claim for mesothelioma treatment, don’t get discouraged. Push for the resources you need, and look for assistance wherever you can find it.
Mesothelioma presents a unique set of health insurance problems because it is so rare. Few medical professionals know how to treat it effectively. To get the best care, patients should seek a mesothelioma specialist, even when it means going outside their insurance network to do it.
Medical Outreach Director and Patient Advocate Missy Miller explains, “A lot of times people just give up when they are told ‘no.’ But you can’t give up. You resubmit the request. You go back to your doctor, and you talk to him about it. We work with patients to help get them approved.”