Finances 101: A Toolkit for Young Adults with Cancer (Affordable Care Act)

1. I wish I’d known there were alternate ways to get something covered. My oncologist told me I had to go the pharmacy for a prescription that quickly maxed out my pharmacy coverage AND cost me $1,000 out of pocket. He said he couldn’t treat me if I didn’t get them, so I just swiped a credit card. Turns out, if I went to his office or the hospital and gotten the injection administered to me, then insurance covered it.

This comment highlights the need to communicate with your health care providers and insurance company. It may take a few conversations with your health care provider and/or insurance company, and you may have to ask a lot of questions about your insurance coverage or alternatives, but in the end you may save thousands of dollars! One positive is that as of January 1, 2014, insurance companies are can no longer impose limits on the amount of benefits that they will pay our for essential health benefits, like prescription drugs. What this means is that if you have met your deductible, insurance companies are required to pay their portion of the cost-share without limitation. You may also be able to benefit from your insurance coverage by getting a prescription from your doctor for certain medicines, even if they are available over the counter.

In addition to prohibiting limits on essential health benefits, most insurance plans now have a strict out-of-pocket maximum. This maximum will include your deductible, co-payments, and cost-share you have paid. If you have a plan that you purchased through your state’s Health Insurance Marketplace, generally the most the out-of-pocket maximum can be is $6,350 for an individual and $12,700 for a family in 2014. For more information on how out-of-pocket maximums work in the marketplace, visit https://www.healthcare.gov/choose-a-plan/out-of-pocket-costs/.

However, it is important to remember that occasionally there are no other alternatives and, given everything else you are coping with, you may not be able to afford even the out-of-pocket maximums. If you are having trouble paying for your prescription drugs, there may be financial assistance available to you. Programs like NeedyMeds and RxHope may be able to help.

2. How do I manage co-pays for surgeries, medications, and treatments?

As discussed above, each health insurance policy may impose a different dollar amount for co-pays for various services. You may have one co-pay amount for prescription drugs and a different amount for in-patient surgery. All of these co-pays will go towards your out-of-pocket maximum.

If you are having trouble paying your co-payments there are some financial assistance options. Programs like the Patient Advocate Foundation’s Co-Payment Relief program and CancerCare‘s Co-Payment Assistance Program may be sources of direct financial assistance. If you aren’t eligible for these types of programs another option may be to set up a personal fundraiser through programs like GiveForward, GoFundMe, or Standbuy.

We also suggest that you work with your healthcare providers. They may be able to group appointments so that you are only having to pay one co-payment or handle certain conversations over the phone, rather than having you come in to the office (e.g., delivering test results or asking follow up questions).

If you have subsequent questions about health insurance, please email us at toolkit@thesamfund.org.

© Triage Cancer 2014. Please note that this information is designed to provide general information on the topics presented. It is provided with the understanding that the experts are not engaged in rendering any legal or professional services by its publication. The information provided should not be used as a substitute for professional services.