Private insurance plans include plans not funded by the government. There are two subcategories of private health insurance, group policies and individual policies. Group health insurance policies are often available through employers, unions and some trade associations. Individual policies and individual family policies are obtained directly from the insurance company, sometimes through an insurance broker. Whether your health insurance is part of a group policy or an individual policy, it could be one of several types:
Health Maintenance Organization (HMO)
In exchange for a premium, an HMO provides comprehensive health care. In a traditional HMO, you have a Primary Care Provider (PCP) as your first contact for almost any insurance-covered service. Your PCP must provide a referral to another provider such as a specialist, hospital, or other health care facility in order for the HMO to cover the service. These providers or facilities usually have a contract with the HMO. When medically necessary, exceptions are made to permit you to use providers or facilities that do not contract with the HMO.
Point-of-Service Plan (POS)
A point of-service plan has slightly more flexibility. The primary care doctors in a POS plan usually make referrals to other doctors or specialists in the plan, but you can go outside the plan. If the doctor or facility you choose is out-of-network, you will usually pay a higher co-pay or co-insurance.
Preferred Provider Organization (PPO)
This type of plan offers the patient access to a network of approved doctors, called in-network doctors or preferred providers. In a PPO, patients typically do not need a referral for specialist care. When using the preferred providers, most of your medical bills are covered. If you use out-of-network providers, the PPO makes you pay more of the bill out-of-pocket.
Fee-for-service plans are rare. They allow you to choose any doctor, change doctors at any time, and go to any hospital in the United States. In a FFS plan, you are responsible for keeping track of your own medical claims and expenses. FFS plans pay only a set percentage of an amount that is usual and customary in your area. The usual and customary rate may be less than the bill from your doctor. You must also meet a yearly deductible before a FFS health insurance policy will begin to pay claims.
Each type of health insurance will provide different coverage in terms of how much you are required to pay out-of-pocket for your care. For example, they will differ in the deductible amount, co-pay or co-insurance amounts, and how much and what types of prescriptions they will cover.
Health insurance plans also include certain coverage limits or restrictions on what the insurer will cover, such as lifetime caps or maximums. Once a patient’s medical bills reach the total benefit limit, the plan no longer has to provide coverage. In some instances, however, insurance companies have agreed to continue to pay for care. You should know your policy’s lifetime maximum. If you begin to approach the policy’s maximum, do not hesitate to discuss this with your providers and insurance case manager. You do have options.
Policies may also include pre-existing condition exclusions. A pre-existing condition is a health condition that you had before you joined your medical plan. If you join a new health insurance plan after you are diagnosed with or treated for cancer, you may have a waiting period before the new insurer will pay any claims they identify as related to the cancer.
If you have enrolled in a policy shortly before you receive a cancer diagnosis, the insurance company may investigate whether the cancer qualifies as a pre-existing condition. This can be scary news. If this happens, check the wording of your policy. Generally, it refers to conditions you knew about or for which you sought treatment or advice before the start of the policy. If you did not know about or receive treatment for the cancer before you obtained the policy, explain that your knowledge of the cancer was not pre-existing.
Employer-sponsored health plans are prohibited from using pre-existing condition exclusion periods in some situations. If you had health insurance with a previous employer and do not have a coverage gap of more than 63 days (continuous coverage), a new plan has to credit the amount of time you had coverage against the plan’s pre-existing condition waiting period (creditable coverage). Pre-existing waiting periods with employer-sponsored group policies are limited to 12 months.
Unfortunately, individual and individual family policies can and usually do have pre-existing clauses. If you have been diagnosed with cancer and are now looking for insurance, it is important to understand what the policy will and will not cover with regard to your cancer care. Be sure you know what the insurance company considers to be related to your cancer care.