How to choose the best health insurance for you

If you think health insurance is confusing, you are not alone.

“Understanding health insurance is challenging for anyone,” says Monica Fawzy Bryant, a cancer rights attorney and chief operating officer for Triage Cancer, an organization that provides free legal and practical education for patients, survivors, and caregivers. “There should be a class in high school on health insurance and finances. These are concerns that we all must navigate but are rarely taught.”

Bryant recently shared key information and reminders to help adult survivors of childhood cancer.
 

Affordable Care Act (ACA) protections

The ACA includes protections that are helpful to cancer survivors:

• Insurance companies cannot refuse to cover health care costs or charge you more based on a pre-existing condition such as cancer. A pre-existing condition is a health problem you had before the date your health insurance starts.
• Young adults can stay on their parents’ insurance plans until they turn 26, even if they are married or offered insurance through their work.
• You can buy low-cost private insurance plans through the Health Insurance Marketplace®. All plans must meet certain requirements. The marketplace offers assistance based on the size of your family and income. About 4 in 5 people can find a policy for $10 a month or less, Bryant says.

Young adults who age out of their parents’ insurance may be able to continue that coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA). But you will likely pay more money out of your pocket than you were paying while working for the company to access that coverage. COBRA only applies to employers with 20+ employees. Certain states may have coverage for smaller employers. Triage Cancer has information on state laws and health insurance options.
 

How to select a plan

When shopping for a plan, Bryant says to look at the total cost and what the plan will cover, and then compare plans. The total cost is more than your monthly premium (what you pay for insurance per month). Total yearly costs include:

• Monthly premium x 12
• Deductible: What you must spend for health care before insurance pays anything (except free preventive services, such as a well visit)
• Copayments: A fixed cost you pay each time you get care (such as $25 per office visit)
• Coinsurance: The portion you pay for covered services (such as 30% of hospital charges)
• Out-of-pocket maximum: The most you spend for covered services in a year. After that, insurance pays 100% for covered services. For Marketplace plans, out-of-pocket expenses include deductibles, coinsurance, copayments, and services that are not covered. Employer insurance plans could be different.
• Do the math: Add these items together. 

Then decide which policy includes the doctors and care you need. Think about these things:

• How much medical care you will need during the year: Make a list of the health care visits, therapy, supplies, and drugs you may need.
• Estimate what you will use: It is good to consider a worst-case scenario. Talk to your primary care provider or your survivorship care team
• What is covered by the plan: Are your providers, labs, and hospitals in the plan’s network (in-network)? Will you have to change providers or pay the higher cost of out-of-network providers? Are your prescriptions covered and at what rate? You can check the insurance plan’s provider directory on its website. You can also call its customer service number listed on the company’s website.

“The best plan for you depends on your situation,” Bryant says. “Generally, people with a cancer history want to be as protected as possible.”
 

Appeal when coverage is denied

Learn what your plan covers. If your insurance denies your claim, you can ask them to reconsider. This is called an appeal. You have at least two chances to challenge the insurance company. An internal appeal is when you ask the company to reconsider. In an external appeal, an outside organization decides if the insurance company should cover the service.

“In one year, there were 48 million denials for plans sold in the Marketplace, and 99.9% were not appealed,” Bryant says. “However, when appealed, between 40–60% of external appeals are decided in favor of the patient.”

For more information on health insurance, visit triagecancer.org and together.stjude.org. Triage Cancer also has a program where you can schedule a call for one-on-one help.