Caribou: Top 7 Cancer Patient Health Insurance Questions

June 25, 2020



June 25, 2020

After a cancer diagnosis, it is common to begin searching for one of the best cancer centers in the world to treat your specific type of cancer. You may be worried about the costs related to this, which is why it’s important to understand what you might expect to pay out-of-pocket (a common term for what your health insurance plan won’t cover). 

Not enough people go through this important step before seeking treatment, but it’s an easy conversation to have with your insurance provider. 

It starts by knowing the most essential questions to ask your insurance representative before scheduling an appointment at a cancer center to ensure you obtain the full benefit from your insurance plan. Leading cancer centers, such as the Moffitt Cancer Center and MD Anderson Cancer Center, recommend verifying your benefit plan and the participating providers in your network. 

Find the contact information on the back of your health insurance card and ask for Member Services, and remember to revisit these questions as you progress through your treatment to make sure nothing has changed regarding your cost of care.

Breaking Down Your Insurance Network

Start by determining your insurance plan type.

1. What type of insurance plan (such as HMO, POS, PPO or short term health insurance) do I have?

Your specific plan will give you information like:

  • The amount of your deductible

  • Whether they require your visit a primary care provider

  • The need for referrals

  • If they’ll provide out-of-network care

Sometimes you must go outside your network for care, but you may be able to reduce your costs if you discuss this with your insurance provider.

2. Is [insert name of desired cancer center] in my network?

  • If so, here are some follow-up questions to ask:

    • Does my insurance plan cover physician costs, virtual visits, as well as inpatient and outpatient hospital services? 

    • Does my insurance plan cover prescription medications and chemotherapy medications?

    • What percentage of my bill does my insurance cover?

    • What, if any, are my co-payments and/or deductible amounts?

  •  If not, you could ask:

    • Does my plan offer access to the cancer centre through a national rental network

    • Which cancer centres are in my provider network?

    • Does my plan have out-of-network benefits? What is the amount of my deductible? If I go out-of-network, what percentage of my bill will be paid by the insurance company?

Your Costs for Cancer Treatment

To know how much to expect to spend, it's important to know your out-of-pocket maximum/limit. After you spend this amount on deductibles and copayments for in-network care and services, your health plan covers all other in-network expenses. 

3. Does my policy have an out-of-pocket maximum? 

  • If so, does this mean that my claims will then be paid in full, or will I still be responsible for the difference?

You will also want to know what your plan covers, including the types of tests and prescription medications. Start the conversation early on what your plan could cover, if needed.

4. Does my insurance plan offer any additional coverage through special networks for treating medical conditions such as cancer?

5. Will I be covered for any testing, pathology, or radiology charges that may be incurred as part of my initial consultation with a cancer center doctor?

6. Do I have pharmacy coverage?

You may be able to reduce your costs by asking your insurance provider how much they will pay and how much you’ll have to pay, or if you can get prior authorization from them to get out-of-network care.

7. Before I see a doctor at [insert desired cancer center], do I need a referral from my primary care physician, or will I need authorization from my insurance carrier?

Getting the Answers From Insurance

Remember that these conversations can be repeated throughout your medical care and that it is alright to make multiple calls with questions as they come up. If you find you are having trouble communicating with your insurance or healthcare providers on the topic of your health insurance plan, don’t hesitate to reach out to Caribou, as our Healthcare Advisors have the expertise to ensure you get the answers you deserve.

Now that you are prepared with questions to ask your insurance provider, it should be easier to start thinking about visiting a Cancer Center. In order to do so, you’ll need to schedule an appointment.