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Mesothelioma and Health Insurance Coverage
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A mesothelioma patient on an employer-sponsored health insurance plan may pay up to $6,000 annually for treatment, while a patient on an individual plan may pay up to $10,000 in coverage a year. Those on Medicare can pay an average of $8,000 annually.
Written by Missy Miller | Edited By Walter Pacheco | Last Update: July 8, 2024
Does Health Insurance Cover Mesothelioma Treatment?
Health insurance does make mesothelioma treatment more affordable. But health insurance remains a controversial topic in the U.S., and cancer treatment is still very expensive in many cases.
The extent of coverage varies by policy. Standard treatments such as surgery, chemotherapy and radiation are typically covered. However, experimental treatments may not be included. Pre-authorization requirements for certain procedures or treatments can affect coverage.
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Coverage also depends on the insurance provider, plan specifics and network agreements. Patients may have to pay co-pays, deductibles and out-of-pocket expenses. Patients with employer-sponsored insurance, Medicare or Medicaid may have different coverage levels and should review their plans closely.
Cost of Treatment With Insurance
A 2020 American Cancer Society Cancer Action Network report estimated how much patients with different types of coverage have to pay for one year of advanced lung cancer treatment. This is comparable to pleural mesothelioma treatment.
$12,046
Estimated annual patient costs for lung cancer treatment.
Patients and families often face extra challenges paying for mesothelioma treatment because mesothelioma is a rare asbestos-related disease. For example, many patients must travel to access a qualified specialist.
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 play a role.
Employer-Sponsored Insurance
Employer-sponsored health insurance in the United States usually provides more affordable coverage. This is because buying health insurance as a group allows a company’s workforce to get better terms.
$5,654
Estimated patient costs for stage 4 lung cancer on employer’s insurance plan.
However, most mesothelioma patients are retired by the time they are diagnosed. Younger patients may have to leave their jobs when they begin treatment.
Insurance is a very complex thing. Some insurance doesn’t cover certain hospitals or providers. We help the patient evaluate if their insurance is actually accepted by the provider or at the hospital. And if it’s not, we help them with their open enrollment to get into a plan that they can actually see a specialist for mesothelioma.
Private Individual Insurance
Americans with individual health insurance policies face high costs for health care. They may have to pay higher monthly premiums because they are not buying health insurance as a group.
$10,114
Estimated patient costs for stage 4 lung cancer on private insurance plan.
The government subsidizes health insurance premiums for low-income Americans. Individual health insurance plans shift costs to patients. They do this through higher deductibles and more expensive copays or coinsurance rates.
Medicare, Medicaid and VA Health Care
Medicare or Medicaid offers coverage to most mesothelioma patients. They are the largest federally funded public health care programs in America. Many mesothelioma patients who are veterans of the U.S. armed forces are also eligible for VA health care benefits.
$8,396
Estimated patient costs for stage 4 lung cancer on Medicaid with Medigap.
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.
Patients need to know they should get treatment in their state for Medicaid to cover the treatment cost. If a patient can prove there are no specialists in their state, Medicaid may approve treatment from a nearby state.
Veterans with mesothelioma can get cancer treatment from the U.S. Veterans Health Administration. This network includes prominent mesothelioma specialists in Los Angeles, Boston, Miami and Houston.
Types of Medicare Coverage
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.
Medicare Options
- 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.
Factors Affecting Insurance Coverage for Mesothelioma Treatment
The type of insurance plan has the greatest impact on coverage, with private insurance, Medicare, and Medicaid offering varying degrees of coverage. Pre-existing conditions, policy specifics and network restrictions also play roles.
Insurance Coverage Factors
- Affordable Care Act (ACA): This 2010 law enacted many reforms that directly benefit mesothelioma patients today.
- 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.
- 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.
- Deductible: How much you have to pay out-of-pocket every year before your insurance coverage kicks in.
- 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.
- Premium: Your monthly payment to stay covered by health insurance. Generally, a higher premium means a lower deductible and lower copays/coinsurance.
A particular treatment’s experimental status can influence coverage because insurers may push back on covering novel therapies or parts of clinical trials.
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. A 2021 report in the Journal of Thoracic Disease concluded that younger age, female sex, non-white race, private insurance, Medicare, and a higher income were associated with better survival.
Survivor Story
Survivor Story
Michael Cole
Pleural Mesothelioma
Mesothelioma Survivor Shares Ups and Downs With Insurance
In 2020, we began having all of my treatment done at UT Southwestern in Dallas. It took about a year to get my insurance to approve it. I am now being treated at Texas Oncology. The insurance company didn’t want to continue paying for me to have treatments at UT Southwestern.
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.”
The best time for financial planning is at the beginning of your mesothelioma treatment. Ask for help understanding the following terms and what they mean for your situation. An insurance company representative, hospital social worker or patient advocate can help.
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