Paying For Chemotherapy

Will your insurance policy cover the cost of your loved one’s chemotherapy? Here are some questions to ask about the cost of your loved one’s treatment.

The cost of chemotherapy varies with the kinds and doses of drugs used, how long and how often they are given, and whether you get them at home, in a clinic or office, or in the hospital. Most health insurance policies cover at least part of the cost of many kinds of chemotherapy. There are also organizations who will help with the cost of chemotherapy and with transportation costs. Ask your nurse or social worker about these organizations. Finding the answers to the questions below will help avoid problems in receiving payment later on.

Questions About Insurance

What Are The Benefits Of My Insurance Plan?

  • What cancer treatments/care does it cover?
  • Do I have a primary care provider? Can I use only certain “preferred providers” under my plan?
  • Am I entitled to a yearly checkup or does my plan only cover office visits when I am sick?
  • What are the benefits if I go outside of my health plan to obtain care?

What Are The Rules Of My Insurance Plan?

  • Do I need a referral from a primary care provider?
  • Do I need a written referral form?
  • Do I need to get approval from my health plan (pre-certification) before seeing a specialist, obtaining treatment, tests, and medical equipment or physical therapy services or going to the emergency room or a hospital?
  • Does my lab work, including blood work, or pap smear need to go to a special lab?
  • Do I have to pay a certain amount (co-pay) at the time of my visit?
  • Do I have an amount that I must pay for medical expenses (annual deductible) before the insurance pays for services?
  • Do I have a lifetime or annual limit on how much is covered for medical expenses?
  • Is there a special pharmacy where I need to get my medications?
  • Are all tests and procedures covered both as an in-patient and out-patient?

Getting Maximum Coverage Of Clinical Trials Costs

Many clinical trials (treatment studies) offer some part of care free of charge. But some insurers will not cover certain costs when a new treatment is under study. Your doctor can work with you to try to help you. If you are taking part in or considering a clinical trial:

  • Ask your doctor about other patients in the trial. Have their insurers paid for their care? Have there been any consistent problems?
  • Talk to your doctor about the paperwork he or she submits to your insurer. Often the way the doctor describes a treatment can help or hurt your chances of insurance coverage.
  • Find out what is in your policy. Check to see if there is a specific exclusion for “experimental treatment.”

Getting The Most From Your Insurance

  • Get a copy of your insurance policies before treatment and find out exactly what your coverage includes.
  • Keep careful records of all your covered expenses and claims.
  • File claims for all covered costs.
  • Get help in filing a claim if you need it. If friends or family cannot help you, ask a social worker for help. Private companies and some community organizations offer insurance-filing aid.
  • If your claim is turned down, file again and inquire about the reasons. Ask your doctor to explain to the company why the services meet the requirements for coverage under your policy. If you are turned down again, find out if the company has an appeals process.

Many insurance companies handle new treatments on a case-by-case basis, rather than having a blanket policy. You can always ask about their coverage of specific therapies. However, some patients say that their questions may have hurt their chances for coverage by raising a red flag. A call from your nurse or social worker to your insurance company about specific coverage may be helpful.

In some states, Medicaid (which makes health care services available for people with financial need) may help pay for certain treatments. Contact the office that handles social services in your city or county to find out whether you are eligible for Medicaid and whether your chemotherapy is a covered expense.

© Copyright FamilyCare America, Inc. All Rights Reserved.

Reprinted from Chemotherapy and You: A Guide to Self-Help During Cancer Treatment, NIH Publication #99-1136, developedby the United States National Institutes of Health National Cancer Institute, June 1999.

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