Mesothelioma and Health Insurance Coverage

Does Health Insurance Cover Mesothelioma Treatment?

Health insurance does make mesothelioma treatment more affordable. But cancer treatment is still very expensive in many cases.

The extent of coverage varies between policies. Standard mesothelioma treatment 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.

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. People with employer-sponsored insurance, Medicare or Medicaid may have different coverage levels and should review their plans closely.

Cost of Treatment With Insurance

A recent 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 treatment for pleural mesothelioma.

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 U.S. 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 when they’re diagnosed. 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. They may have to pay higher monthly premiums because they’re not buying health insurance as a group.

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 covers most mesothelioma patients. They’re the largest federally funded public health care programs in the country. Many veterans with mesothelioma are also eligible for VA health care benefits.

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 4 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 you have is the biggest factor affecting coverage. Private insurance, Medicare and Medicaid each offer different levels of benefits. Other important factors include pre-existing conditions, the details of your policy and whether your providers are in-network or out-of-network.

Insurance Coverage Factors

• Affordable Care Act: The ACA, passed in 2010, includes many protections that benefit mesothelioma patients today.
• Balance billing: Sometimes, when your doctor or hospital charges your insurance, the insurance may not pay the full amount. If this happens, you may be billed for the leftover balance. This often occurs if you use a provider outside your insurance plan’s network without knowing it.
• Copay and coinsurance: These are the amounts you must pay even when insurance covers part of your care. A copay is a fixed fee for each service. Coinsurance means you pay a percentage of the bill.
• Deductible: This is the amount you must pay out-of-pocket each year before your insurance starts to pay.
• In-network vs. out-of-network: Insurance plans have a network of doctors, hospitals and pharmacies where your costs are lower. Because mesothelioma is rare, you might need to see a mesothelioma doctor who isn’t in your network, which can increase your costs.
• Out-of-pocket maximum: This is the most you have to pay in a year for covered services. After reaching this limit, your insurance usually pays 100% of covered costs for the rest of the year. In 2019, these limits were $7,900 for individuals and $15,800 for families.
• Premium: Your monthly payment to keep your insurance active. Usually, plans with higher premiums have lower deductibles and copays or coinsurance.

Whether a treatment is considered experimental can also affect whether insurance covers it. Insurers sometimes refuse to pay for new therapies or parts of clinical trials.

The ACA set rules that insurance plans must follow, including covering cancer screenings, treatment and follow-up care. It also stopped insurance companies from setting lifetime or yearly limits on cancer treatments. Most importantly, the ACA prohibits dropping patients with serious illnesses or refusing coverage because of pre-existing conditions like cancer.

What if My Health Insurance Claim Is Denied?

If your insurance company refuses to pay for mesothelioma treatment, don’t lose hope. Keep trying to get the help you need. Look for assistance wherever possible.

Mesothelioma is rare, and few doctors know the best ways to treat it. To get the best care, patients should try to see a mesothelioma specialist, even if that doctor is outside of their insurance network.

As the Medical Outreach Director and Patient Advocate at The Mesothelioma Center, I often see people give up when they hear ‘no.’ But you can’t give up. You should resubmit the claim. Talk with your doctor about it. We work with patients to help get them approved.

The best time to plan your finances is at the start of your mesothelioma treatment. Ask for help understanding terms like copays, deductibles and out-of-pocket limits. Hospital social workers, patient advocates or insurance representatives can help explain what these mean for you.

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