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Health Insurance

A health insurance policy is a legal agreement where an insurer gives coverage for some or most of your medical care costs for a certain price. That price is called a premium.

If you work for a large company, the premium may be paid by your employer. If not, you may buy insurance on your own or through a group.

Health insurance can also be provided by the federal or state government, such as Medicare (for people over age 65) or Medicaid (for people with a low income).

Types of health insurance

The basic types of health insurance are:

Each type has pros and cons.

For example:

  • A fee-for-service plan gives the most flexibility, but you pay more in terms of money and time (such as time spent doing paperwork). 
  • With an HMO, you pay less, but you have fewer choices. 
  • With a preferred provider organization, you can leave your options open and balance flexibility and cost each time you make a health care decision.

Fee-for-service plans give the most options in choosing health care providers and treatment centers.

However, these plans typically cost more and require more time doing paperwork.

Co-payments and deductibles

In a fee-for-service plan, insurance will only reimburse part of medical costs (for example, you might pay 20 percent of the cost and the insurer pays 80 percent). The part paid by you is called the co-payment or co-insurance.

You may have to pay a deductible (a pre-set amount of your medical costs each year before the insurance payments begin).

No matter how much you pay in terms of the co-payment and deductible, the insurer makes the final decision on whether a certain procedure or cost will be reimbursed. You may have to get approval before the procedure is done. Sometimes, the insurer requests more information from the doctor.

Time on paperwork

In a fee-for-service plan, you may spend more time coordinating your medical care and filing for reimbursement than with other plans.

You must keep track of your own expenses, such as receipts for drugs and other medical costs. To get reimbursed for costs covered in your plan, you may have to fill out claim forms and send them to the insurer.

With a health maintenance organizations (HMO), you must use health care providers and medical centers that belong to the plan.

Your care is coordinated through your primary care provider, who controls all referrals to specialists.

Although you have fewer options for heath care providers and treatment centers than with a fee-for-service plan, you pay less for medical care.

Premiums, co-payments and deductibles

Most of an HMO’s services are covered by the monthly or quarterly premiums. Often, there’s a deductible. You usually have a co-payment for office visits and hospital stays.

Time on paperwork

With HMO plans, you rarely need to submit claims forms for reimbursement. So, you usually have less paperwork and less record-keeping than with a fee-for-service plan.

A preferred provider organization creates a network of hospitals, doctors and other health care providers.

You can make choices on a service-by-service basis. You can see a health care provider from within the plan’s network and have most of your medical expenses covered, or you can see a provider from outside the network and have fewer expenses covered.

Often, there’s a deductible for a preferred provider organization plan.

There’s trade-off between cost and flexibility with each type of health insurance.

No option is right for everyone. Weighing the pros and cons can help you choose the plan that’s right for you.

 ProsCons
Fee-for-service planOffers the most options in choosing health care providers and treatment centersOnly covers a portion of medical costs

May have a deductible

Insurer makes the final decision on whether a procedure or cost is reimbursed

Must coordinate your own medical care, track all expenses and file for reimbursement (lots of paperwork) 

Health maintenance organization (HMO)Costs less than a fee-for-service plan

Pay premiums and small co-payments for office visits and hospital stays

Rarely need to submit claim forms for reimbursement

Less record-keeping (paperwork) compared to a fee-for-service plan

May have a deductible
 
Must choose health care providers and treatment centers that belong to the plan (limited number of each)

Care is coordinated through a primary care provider who controls all referrals to specialists

Preferred provider organizationBlend of a fee-for-service plan and an HMO

For each medical service, you can choose a health care provider and treatment center from within the plan and have most expenses covered or you can choose a provider and treatment center outside the plan and have fewer expenses covered

May have a deductible

May be more expensive than an HMO plan

May have more record-keeping (paperwork) than an HMO plan

 

Getting health insurance

If you don’t have health insurance, you can get coverage by:

  • Buying group insurance through your employer or other organization (such as a union or civic group)
  • Getting coverage through federal and state programs (such as Medicare and Medicaid), if you are eligible
  • Getting coverage on your parent’s health plan (if you’re under 26)

Pre-existing conditions

As part of the Affordable Care Act, insurance companies can’t limit coverage based on a pre-existing condition (such as breast cancer). 

 

Group insurance

Although employers are the main source of group insurance coverage, organizations such as unions, professional associations, churches and civic groups may also offer insurance to their members.

These policies are set for a group of people rather than one person, so the premiums tend to be lower than individual insurance.

Individual insurance

When you buy insurance as an individual, you usually pay higher premiums than through group insurance. However, in some cases, individual policies give more options that tailor benefits to your needs.

To find out more about buying individual insurance, contact an insurance agent or broker, your state insurance commissioner’s office or your state health department.

Medicare is health insurance provided by the federal government to people who are 65 or older, on renal dialysis or permanently disabled.

Medicare Part A and Part B

Basic Medicare has 2 parts:

  • Medicare Part A covers hospital costs and most out-patient appointments.
  • Medicare Part B covers medical costs, including some equipment, supplies and ambulance transportation.

Medicare doesn’t provide comprehensive health care. However, as part of the Affordable Care Act, it covers a yearly wellness visit, screening mammograms and some other preventive services.

Medicare doesn’t directly pay for prescription drugs, although there are insurance companies that work with Medicare to help cover the costs of medications.

Medicare also doesn’t cover experimental treatments or services outside the U.S.

Medicare plans have co-payments and deductibles.

Medicare advantage plans

Medicare Part C (Medicare advantage plan) is run by private insurance companies (such as health maintenance organizations (HMOs) and preferred provider organizations) under contract with Medicare.

Medicare Part C includes Part A and Part B, but costs for services vary depending on the plan. Some plans offer prescription drug coverage.

Medicare prescription drug coverage

Medicare Part D (Medicare prescription drug coverage) is run by private insurance companies under contract with Medicare. These plans help cover prescription drug costs.

For more information about Medicare, call the Medicare Hotline at 1-800-MEDICARE (800-633-4227) or visit www.medicare.gov.

A Medigap policy is private supplemental (extra) insurance that fills in “gaps” of Medicare coverage. It pays for some Medicare costs (like co-payments) and some services not covered by Medicare Part A and Part B.

If you have Medicare Part A and Part B (and don’t have a Medicare advantage plan), you can buy a Medigap policy.

There are many Medigap policies. The most basic plan covers items such as the co-payment for Medicare Part A hospital stays. Other Medigap plans cover items such as recovery at home and some prescription drugs costs.

For more information about Medicare or Medigap, call the Medicare Hotline at 1-800-MEDICARE (800-633-4227) or visit www.medicare.gov.

Medicaid provides health care to people who have a low-income. This program is run jointly by the federal government and state governments. So, benefits and eligibility (who can join) vary from state to state.

Your state may have a different name for Medicaid. For example, in Maine the program is called MaineHealth and in California, it’s called Medi-Cal.

You also may be eligible for Medicaid if you have very high medical expenses, even when your income level is too high to qualify.

For more information about Medicaid, call your state’s toll-free hotline. 

 

Dealing with problems

Insurance problems are stressful. If a claim is denied or if you change (or lose) your job during breast cancer treatment, there are things you can do. There are laws to protect you. 

If a health insurance claim is denied, these steps may help resolve the problem:

  • Keep copies of all correspondence (such as letters and e-mails) with the insurance company about the claim. Note the claim number and policy or procedure code on all correspondence. Also, note the name of any customer service or claims representative you speak with on the phone. 
  • Call the insurance company to find out why the claim was denied. If it’s still unclear, study the explanation of benefits (EOB) form. In some cases, the denial may be the result of a claim being improperly recorded (such as a service being omitted by mistake). 
  • Check the facts. Review your policy to make sure pre-certification, authorization and other procedures required by the insurer were followed. For example, claims for prosthetic bras, implants and wigs may need a copy of the prescription and the bill. 
  • Ask your doctor for help if fees, charges or procedures are questioned. Most doctors and their staff are used to working with insurance companies and can help answer questions. Ask your doctor to write a letter to the insurance company recording and justifying the charges or procedures. Be sure to keep a copy of this letter. 
  • If the claim is denied because the insurance company says a treatment is experimental or under study, ask your doctor to help. If your doctor can give the insurance company proof the scientific literature supports the use of a certain treatment, then it can’t be called experimental. Your doctor can get published studies as well as support letters from other oncologists using the same procedure. National organizations, such as the Patient Advocate Foundation, can also help. 
  • Ask for a formal review of the denied claim. Often, claims that were first denied are paid in later reviews. If this fails, ask for an appeal of the review using outside cancer experts to review the medical records and claim.

If these steps fail to get payment for a claim you and your doctors believe is justified, a final option is to contact a lawyer.

National patient support organizations, such as the National Cancer Legal Services Network, can help find lawyers in each state who work on cancer-related insurance issues.

The Patient Advocate Foundation offers help resolving problems and help with insurance issues involving insurers, employers and creditors.

There are laws to protect you from losing health insurance coverage if you lose your job, change jobs or need to take time off during your breast cancer treatment. These are described below.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

COBRA protects people who are covered by a group health insurance plan through an employer with 20 or more employees.

Under COBRA:

  • You must be offered continuous coverage for up to 18 months after leaving your job.
  • You must request this coverage within 60 days of leaving the job, and in turn, your employer has to give you written notice of your COBRA rights within 14 days of leaving the job.
  • You pay the entire premium on the insurance. While that premium can be large, it’s less than the cost of buying an individual policy (group rates are usually lower than individual rates).

If you’re not covered by COBRA (for example, if you work for a company with fewer than 20 employees), you may be able to switch your group coverage to an individual policy. 

Although your premiums will likely increase, this may be a good short-term solution while you look for other options.

Family and Medical Leave Act of 1993

The Family and Medical Leave Act helps protect people from losing their jobs when they need to take time off for family and medical reasons. It allows you to take up to 12 weeks of unpaid leave within a 12-month period of time, without losing your job.

If you have a company group health plan, your employer must continue your health insurance coverage during the unpaid leave. If you are unable to work due to your treatment or the cancer itself, you are eligible. Any immediate family members (defined as a spouse, child or parent) who are caregivers are also eligible.

Having this job security allows you to take more time off once paid vacation or sick days are used up.

This law covers most people who have been working for their employer for at least 12 months.

Pre-existing conditions

As part of the Affordable Care Act, insurance companies can’t deny or limit coverage based on a pre-existing condition, such as breast cancer.

If get a new employer-based insurance plan or individual health insurance plan, the insurance company can’t deny or limit your coverage because you’ve been diagnosed with breast cancer.

 

Susan G. Komen® Support Resources

  • Do you need help? We’re here for you. The Komen Patient Care Center is your trusted, go-to source for timely, accurate breast health and breast cancer information, services and resources. Our navigators offer free, personalized support to patients, caregivers and family members, including education, emotional support, financial assistance, help accessing care and more. Get connected to a Komen navigator by contacting the Breast Care Helpline at 1-877-465-6636 or email helpline@komen.org to get started. All calls are answered Monday through Thursday, 9 a.m to 7 p.m. ET and Friday, 9 a.m. to 6 p.m. ET. Se habla español.
  • The Komen Breast Cancer and Komen Metastatic (Stage IV) Breast Cancer Facebook groups are places where those with breast cancer and their family and friends can talk with others for friendship and support.
  • Our fact sheets, booklets and other education materials offer additional information.

Updated 05/29/24

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