Understanding Health Insurance

Prostate cancer is complicated and so is health insurance. It will be very helpful for you or someone you trust to become an expert in understanding and managing your insurance coverage for prostate cancer treatment. Most people obtain their insurance through their employer or through government programs such as Medicare or Medicaid. Coverage is also available through the Affordable Care Act.

Types of health insurance

The type of health insurance coverage you have plays a big role in the amount of out-of-pocket costs you can expect to pay through cancer treatment and recovery. The following information will help you understand the different types of health insurance and what medical costs they usually cover.

Private Insurance

• This type of plan generally doesn't place any restrictions on which doctors or hospitals you choose. Typically, you share some of the cost in the form of copayments or co-insurance, and some types of services may not be covered.
• Although fee-for-service plans allow for the greatest freedom in choosing doctors and hospitals, there may be restrictions to some services, including mental health services, physical therapy, home healthcare, investigational treatments, or complementary therapies.

HMO – Health Maintenance Organization

• An HMO can be thought of as a healthcare insurance club, with patients and doctors as members. It is set up to keep healthcare costs down by working with patients to comprehensively manage their healthcare. In an HMO, a person chooses a primary care doctor from an approved network and receives referrals to see physicians other than the primary care.
• As a member of an HMO, you pay a monthly premium and a small additional copay for each office visit. An HMO generally doesn't require you to submit any claim forms, unless you visit doctors who are not members of the plan, also called ‘out of network.’

PPO – Preferred Provider Organization

• A PPO is a type of health insurance in which a person is offered a network of approved doctors, and most of the medical costs are covered when visiting doctors that are part of the network. However, a PPO typically doesn't require you to see a designated primary care doctor who manages your care and controls your access to a specialist. It may also require you to pay a deductible or co-insurance for some services.

Government-sponsored insurance programs

Medicare

• Medicare is health insurance provided by the federal government for people 65 and older, as well as for some disabled Americans. People over 65 who are eligible for Social Security or Railroad Retirement benefits automatically qualify for Medicare, along with their spouse. Medicare has different “parts” that serve different, sometimes complementary, purposes.
  • Medicare Part A covers hospital care, skilled nursing care, hospice care, and some home care services.
  • Medicare Part B provides coverage for doctor services, outpatient care, physical and occupational therapy, and selected supplies that are deemed medically necessary. You may be responsible for 20% of the cost depending upon your plan.
  • Medicare Part C, also called Medicare Advantage, contains insurance plans managed by private Medicare-approved companies. It combines Medicare Parts A and B and may include prescription drug coverage.
  • Medicare Part D is a benefit that covers prescription drugs. Depending on your Medicare plan you may be responsible for 20% of the cost. Some people with Medicare prescription drug coverage may be eligible for extra help.
• Medigap policies are available for purchase to help pay the costs that aren't covered by Medicare.

Medicaid

• Medicaid is a health insurance program paid for by the federal and state governments and administered by each state. It covers people who are eligible because they are elderly, blind, or disabled, as well as certain people in families with dependent children. Each state operates the program individually and determines who is eligible and what services are covered in that specific state.

Health insurance marketplaces

• Also called exchanges, the marketplaces are a newer way to choose and purchase health insurance. Depending on where you live within the United States, you can compare different health insurance plans and prices and find one that works best for you.

Department of Veterans Affairs health benefits

• The Department of Veterans Affairs (VA) provides health benefits and services for eligible Veterans who served in active military service. Some members of the Reserves or National Guard are also eligible. There are several requirements you must meet for eligibility and it is important to contact the VA directly if you think you are eligible for health services. Coverage generally includes treatments, procedures, supplies, or services.
• For Veterans who are already enrolled in VA healthcare, the Choice Program allows you to receive healthcare within your community without impacting your existing VA healthcare or any other VA benefit. If you have been, or will be, waiting more than 30 days for VA medical care, if you live more than 40 miles away from a VA medical care facility, or if you face certain travel burdens, you may be eligible for this program. Visit va.gov/communitycare for more information.

TRICARE

• TRICARE is the healthcare program for uniformed service members (active, Guard/Reserve, retired) and their families around the world. TRICARE is a major part of the Military Health System and offers an expansive provider network offering services in military hospitals and clinics and civilian healthcare networks.

Other types of insurance

Although health insurance covers some of the costs of cancer care, other costs are not covered. Many of these additional expenses may be covered if you have purchased other types of insurance.

Supplemental insurance

A supplemental insurance policy helps cover expenses not covered by your primary insurance or the costs you pay as part of your existing plan. This policy generally covers deductibles, co-insurance, copays, and other out-of-pocket expenses. It may also offer additional benefits, such as compensation for lost earnings due to missed work.

Disability insurance

Disability insurance replaces income lost if you are unable to work due to a long-term illness or injury. Such coverage is often provided through your employer or government-sponsored programs, although individual policies are also available.

Hospital indemnity insurance

Hospital indemnity insurance provides limited coverage for hospital stays, usually a fixed amount each day up to a maximum length of stay. You may decide to purchase this type of insurance if your basic insurance plan limits coverage of hospital care.

Long-term care insurance

Because most basic private insurance plans and Medicare generally provide very limited coverage for long-term care, such as nursing home care, you may decide to get additional coverage to offset the costs of such care.