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Health insurance coverage for mesothelioma helps pay the costs of the expensive treatments needed to manage this cancer. Mesothelioma patients may have several options: group health insurance through work, private insurance through state marketplaces, public programs like Medicare, or veterans’ benefits.
What Are the Costs of Treating Mesothelioma?
The costs of treatment for any kind of cancer are generally high. Because mesothelioma is rare and requires specialist care, it usually costs even more to treat. Based on studies, average costs for some mesothelioma diagnostic procedures and treatments are:
- $16,575 for a pleural biopsy
- $19,899 for a thoracentesis
- $38,779 for a course of standard chemotherapy
- $53,993 for a pleurectomy/decortication
- $62,408 for a pneumonectomy
How Health Insurance Works
Every insurance plan is different, but they generally work in a similar way, whether it’s a private or government program:
- You will pay a monthly fee for your insurance plan, called a premium.
- Most plans require beneficiaries to cover a co-pay or percentage of the cost of each medical service or visit to a doctor’s office.
- The deductible is the amount of money you have to pay for care out of pocket before insurance coverage kicks in for a given year. People undergoing cancer care are likely to reach this point early, while healthy people might not ever reach it.
- The plan also sets an out-of-pocket maximum that you must pay for care before the insurer will cover 100% of covered services.
Most doctor’s offices and other care providers will bill your insurer for you. The insurer will then bill you for any expenses it does not cover. It’s important to keep track of these figures in the event you dispute any charges.
What Health Insurance Covers for Mesothelioma Patients
Health insurance is important for everyone; however, it is especially important for those fighting aggressive cancers like mesothelioma. Care is expensive, and most individuals cannot afford it without help. Uninsured patients may not receive the care and treatments they need.
Insurance coverage for a mesothelioma patient depends on the details of their specific plan. In general, insurance plans cover the costs of diagnostic tests and treatment for cancer, but most plans will not cover 100% of these costs.
Most patients will have to cover co-pays and deductibles, which can be expensive. Even with these costs, insurance can make a significant difference. For example, the cost of a cycle of chemotherapy, without insurance, may cost as much as $30,000. Surgery can be even more expensive.
The law now requires that care providers and insurers provide people with cost information before providing services. If they do not provide this information, ask before committing to services.
Types of Health Insurance Plans
Whether you have access to a plan through your employer or are purchasing insurance, it helps to understand the different types and options:
- Managed Care. Managed care plans coordinate enrollee health care and are often used by employers for their employees. They usually have lower premiums and co-pays than other kinds of plans. Types of managed care include HMOs, PPOs, and POS plans.
- Health Maintenance Organization (HMO). An HMO is managed care with a limited network of providers. If you go outside the network, the plan may not cover any of the costs.
- Point-of-Service (POS). A POS plan is a type of HMO, in which you work with a primary physician, who refers you to other providers as needed.
- Preferred Provider Organization (PPO). A PPO gives you more options than an HMO but also includes a network of providers. If you go outside the network, you will pay more.
- Fee-for-Service Plans. These plans are the least restrictive and allow you to see any care provider that accepts your insurance plan.
With a cancer like mesothelioma, it’s likely you’ll need to go out of network to see specialists. Stay in contact with your insurer about these needs to find out what will be covered or to get pre-authorization to go out of network. You can also negotiate costs with care providers if your insurance doesn’t cover everything.
Private Health Insurance
Private health insurance is any kind of 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.
Many workers or retired workers have coverage through a group plan where their employer covers part of the cost of premiums. The benefit of a group plan is that costs are lowered because there are more people enrolled in the plan. Often these plans also cover an employee’s dependents.
Private health insurance plans come in many different forms. Managed-care plans, like HMOs, and preferred provider plans are private plans. This may mean having a limited network of healthcare providers or requiring a primary care provider to coordinate other care.
In addition to these comprehensive types of insurance, people can purchase specialized and supplemental insurance. For example, catastrophic coverage 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 often include supplemental cancer insurance or catastrophic coverage.
Can You Still Get Insurance After a Cancer Diagnosis?
The Affordable Care Act (ACA, or Obamacare), passed in 2010, banned the practice of refusing coverage to people with pre-existing conditions. Previously, insurers could reject you for having a cancer diagnosis, or any other diagnosis.
The practice is now illegal, so you can purchase insurance even after finding out you have mesothelioma. You can also expect to get a fair price. The ACA outlawed charging people more for pre-existing conditions.
Before purchasing or enrolling in any health insurance plan, do your homework. Find out what it will cover in terms of cancer care. Not every plan is the same. With a health condition like mesothelioma, you need to choose your plan carefully to maximize coverage and minimize expenses.
Many people rely on public insurance plans. Public insurance plans include those funded by the federal government, like Medicare and Medicaid.
Does Medicare Cover Mesothelioma?
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 benefit from the insurance program. Some younger workers with disabilities also qualify.
Part A Medicare is available to all who qualify for Medicare. It covers basic care. Medicare Part B has an additional premium cost and covers more care. Part C is a combination of parts A and B. Part D covers prescription drug costs.
Does Medicaid Cover Mesothelioma?
Medicaid is a health insurance plan for people who fall below a minimum income level and do not qualify for Medicare. Many people with mesothelioma do qualify for Medicare because it is occurs most often in older adults.
The Affordable Care Act
President Obama signed the Affordable Care Act (ACA) in 2010 and it went into effect in 2014. The law makes it easier for low-income individuals and families to purchase health insurance plans. The ACA changed several things about the insurance industry that benefit cancer patients:
- Individuals without private insurance, 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 the marketplace. They may also find financial assistance in buying a plan.
- The ACA outlawed preexisting condition limits and denials of coverage.
- The law sets minimum standards for health insurance that includes screenings, treatment, and follow-up care for cancer patients.
- The law also ensures healthcare plans will cover clinical trials; although, plans may have varying levels of reimbursement. It is important to ask these questions before enrolling should you be interested in enrolling in a trial.
Patients are often responsible for some care costs during a clinical trial, so not having insurance could prevent participation for some.
Health Insurance and Pre-Existing Conditions Under ACA
The ACA changed the rules regarding pre-existing conditions. Before the law, health insurance plans could deny coverage for a diagnosed condition, like mesothelioma.
Those insurance plans that did accept pre-existing conditions could impose an exclusion period. This meant the patient would not receive payment for healthcare costs related to the pre-existing condition for a certain period of time. For patients with mesothelioma, time is of the essence, so that exclusion period could cost someone their life.
The ACA prohibited preexisting condition exclusion periods and has made it illegal for health plans to deny coverage due to a preexisting condition. “Grandfathered” plans are an exception. Grandfathered plans were those already in place when the ACA was signed into law.
All new plans must follow the new rules regarding preexisting conditions. As time passes, the number of grandfathered insurance plans will decrease. This is because these plans lose their grandfathered status if they make coverage or pricing changes.
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, which is important because many veterans were exposed to asbestos while serving.
Coverage for veterans eligible for VA benefits is extensive, covering most of the cost of diagnosis, treatment, and care.
Unfortunately, some criminals will take advantage of vulnerable people looking for affordable health insurance. Beware of discount health insurance, stripped-down policies, and medical discount cards.
Scammers also create fake websites that appear to be official insurance marketplaces. If you are purchasing through a marketplace, always start with healthcare.gov. Healthcare.gov is the only official marketplace. Always be wary of someone who contacts you to sell you insurance. Real insurance plans do not sell aggressively.
If you have mesothelioma and have found an insurance plan, make sure you understand the benefits, coverage, and whether you need supplemental insurance. The costs of treating mesothelioma are high, but it is a life or death matter. If you are ever unsure of your options or coverage, talk to your doctor.Get Your FREE Mesothelioma Packet
Page Medically Reviewed and Edited by Anne Courtney, AOCNP, DNP
Anne Courtney has a Doctor of Nursing Practice degree and is an Advanced Oncology Certified Nurse Practitioner. She has years of oncology experience working with patients with malignant mesothelioma, as well as other types of cancer. Dr. Courtney currently works at University of Texas LIVESTRONG Cancer Institutes.