Covering the Cost of Cancer Care
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Getting cancer makes you feel like you have no control. Remember you, the patient, still make the decisions. Before you accept or reject a specific treatment, understand your physician's rationale, review the costs, and know your rights.
Thanks to the Affordable Care Act (ACA), your insurer can't reject you for pre-existing conditions, rescind coverage after your diagnosis, place lifetime limits on how much they'll spend on your care, or charge you higher premiums because you are sick.
In addition, if you have an ACA compliant plan, your insurer must offer free tobacco cessation counseling and screening colonoscopies. They must cover, but not necessarily in full, breast cancer screening (mammography) and cervical cancer screening (pap smears). In addition, women at high risk for genetic forms of breast cancer will be covered for genetic screenings and chemopreventive medications like Tamoxifen.
Even with these new protections, you need to be proactive to ensure you receive the above-mentioned benefits. Don't assume your physicians will remind you. They, like all of us, may overlook important recommendations. The same is true with your insurer. Don't assume they will look out for you; it's not in their financial interest to do so.
With the average monthly cost of a new cancer drug around ,000 a month, insurers don't have much incentive to find you the latest and greatest treatment options. Many types of chemotherapy now come in pill form, which you can purchase at the pharmacy. ACA-compliant insurers can place prescription drugs in certain tiers. The higher the tier, the higher the co-pay and co-insurance. Chemotherapy pills, if covered, will likely be in the highest tier. According to the American Cancer Society (ACS) website, your co-pay may be 25 percent of the drug's total cost. Unlike inpatient medications, you have to pay this cost up front.
If your health plan won't cover an essential drug, a physician can certify the drug is medically necessary and request the insurer cover you for it. If the insurer continues to deny coverage, you can request an internal appeal. The insurer must respond within 72 hours of the appeal. If the internal appeal fails, you can request an independent external review of the insurer's list of covered drugs (formulary). The insurer must follow the independent reviewer's decision.
Should your external appeal fail, you may qualify for an "approved clinical trial" that is studying the drug you desire.These trials use human subjects to research ways to prevent, detect, or treat cancer and other life-threatening conditions. The trial sponsor, usually the federal government, will pay for the treatment they are studying. Your ACA-compliant insurer must allow you to participate in such trials and must continue to provide you the same benefits they provide all of their enrollees.
To be eligible for all these benefits, you must buy an ACA-compliant plan. If you are still shopping for coverage, you must purchase an ACA plan by March 15 for coverage to start April 1. The last day to sign up is March 31. If you miss that deadline, you will have to wait until 2015 to receive coverage.
Remember to send me your thoughts and questions via email, follow me on Twitter, or post your comments and questions directly on this page.
I look forward to hearing from you.
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