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Health Insurance Coverage for Mesothelioma

Getting a diagnosis of mesothelioma can be devastating. It is a death sentence for most patients, with little to no hope of a cure from treatment. Patients receiving this diagnosis will also have to worry about the costs of care. Treating cancer is expensive and trying to pay for it without health insurance is impossible for most people. Mesothelioma patients may have several options: group health insurance through work, private insurance bought through the state marketplaces, public programs like Medicare, or veterans’ benefits.

What Health Insurance Covers for Mesothelioma Patients

Having health insurance is important for all people, but especially for those fighting for their lives against cancers like mesothelioma. The costs of care can be very high and most individuals are unable to cover those costs without assistance. Without insurance patients may not get the care they need. Exactly what an insurance plan will cover for a mesothelioma patient depends on the details of the specific plan.
In general, insurance plans cover the costs of diagnostic tests and of treatment for the cancer. Most plans, though, will not cover 100 percent of these costs. Most patients will have copays and deductibles, which can be high. Even with these costs, having insurance can make a big difference. The cost of a cycle of chemotherapy, for instance, without insurance may cost as much as $30,000, and surgeries are often even more expensive.

Private Health Insurance Types

Private health insurance is any kind of insurance plan that is not a government program. People with private insurance may be part of a group plan through their workplace, or may have purchased an individual plan. Group plans through work include many people and the employer pays part of the cost of premiums. The benefit of a group plan is that with more people on the plan, the costs are lowered. These plans also cover dependents of the employee.

Private health insurance plans come in many different forms. There are managed care plans, like HMOs, and preferred provider plans, which manage enrollee health care. This may mean having a limited network of health care providers or requiring a primary care provider to coordinate other care. Fee for service plans are the least restrictive plans and allow the enrollee to go to any health care provider that will accept the insurance plan.

In addition to these more comprehensive types of insurance, there are more specialized and supplemental types. Catastrophic coverage, for instance is a low-cost plan with high deductibles. Enrollees pay low premiums, but coverage only kicks in after high deductibles have been met. Supplemental plans can be bought to add extra coverage and these include supplemental insurance for cancer.

Government Programs

Many people rely on public insurance plans, those funded by the federal government, including Medicare and Medicaid. Medicare is a health insurance plan for people over the age of 65. These older retirees paid into the system throughout their working lives and then later are able to benefit from the insurance program. Part A Medicare is available to all who qualify for Medicare and it covers basic care. Part B has an additional premium cost and covers more care. Part C is a combination of parts A and B and Part D covers prescription drug costs. Medicaid is a health insurance plan for people who fall below a certain minimum income level and who do not qualify for coverage through Medicare.

The Affordable Care Act

The Affordable Care Act (ACA) was signed into law in 2010 and went into effect in 2014. The law has made it easier for low-income individuals and families to purchase health insurance plans and it has also outlawed pre-existing condition limits and denials of coverage, an important change for people with all types of cancer who need coverage. Individuals without private insurance through workplace programs, or who do not qualify for Medicare or Medicaid, can buy insurance through state- or federal-run marketplaces. Individuals whose workplace group insurance plans are too expensive, can also opt to purchase a plan through a marketplace. There may also be assistance available to help some people pay for a plan.

In addition to the limit on pre-existing condition exclusions, the ACA has helped cancer patients in other ways. For instance, the law set minimum standards for health insurance plans that include screenings, treatment, and follow up care for cancer patients. The law also ensures that patients participating in clinical trials will be covered by health insurance plans. Patients are often responsible for some of the costs of care during a clinical trial, so not having insurance coverage may prevent some from participating.

Health Insurance and Pre-Existing Conditions

The ACA changed the rules regarding pre-existing conditions. Prior to the federal law being enacted, health insurance plans could deny you coverage for having a diagnosed condition, like mesothelioma, before joining the insurance plan. Those insurance plans that did accept people with pre-existing conditions, usually group rather than individual plans, could impose an exclusion period. This means the patient would not receive payment for any health care costs related to the pre-existing condition for a certain period of time, as much as a year. For someone with mesothelioma, a year could be too late.

The ACA has prohibited pre-existing condition exclusion periods and has made it illegal for health plans to deny anyone coverage because of having a pre-existing condition. Exceptions to this are plans that were “grandfathered.” These are plans that existed already at the time the ACA was signed into law. All new plans from that time forward had to follow the new rules regarding pre-existing conditions. As time passes, the number of grandfathered insurance plans is going down. As these plans make coverage and pricing changes they lose the grandfathered status.

Veterans Insurance and Benefits

The U.S. Veterans Health Administration provides health benefits for many veterans. The national network for veterans includes specialists who treat mesothelioma patients. This is important because a significant proportion of patients diagnosed with mesothelioma are veterans who were exposed to asbestos while serving. Coverage for veterans with mesothelioma who are eligible for VA benefits is extensive and takes care of much of the cost of diagnosis, treatment, and care.

Insurance Scams

Unfortunately there are criminals that will try to take advantage of vulnerable people looking for health insurance that is affordable. Watch out for things like discount health insurance or stripped-down policies and medical discount cards. Scammers have also created fake websites that look like official insurance marketplaces. If you are purchasing through a marketplace, always start with healthcare.gov, the only official site for using the marketplaces. Always be wary of someone who contacts you to sell you insurance. Real insurance plans do not sell aggressively.

If you have mesothelioma and you have found some type of insurance plan, make sure you understand the benefits, what is covered, and whether you need supplemental insurance of any kind. The costs of treating mesothelioma are high, but it is a matter of life and death. If you are ever unsure of what your options are through your health insurance plan, talk to your doctor. Specialist care through insurance plans can get complicated, but getting that care is important.

Page edited by Dave Foster

Dave has been a mesothelioma Patient Advocate for over 10 years. He consistently attends all major national and international mesothelioma meetings. In doing so, he is able to stay on top of the latest treatments, clinical trials, and research results. He also personally meets with mesothelioma patients and their families and connects them with the best medical specialists and legal representatives available.

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