Laurie M. Robbins, BSN, RN, CBCN®

Elaine S. DeMeyer, RN, MSN, AOCN®, BMTCN®

Cancer Nursing Today nonprod

As a nurse, are you ever confused about your own insurance coverage? Imagine the confusion of someone newly diagnosed with cancer. Cancer survivors and caregivers often have many questions about insurance. These are the 3 most common concerns of patients and caregivers that I try to address in my role as an oncology case manager. As an oncology nurse, you may not know all the answers, but you should know who does.&nbsp;<h2>What are some of the most common question cancer survivors and caregivers ask about their insurance?&nbsp;&nbsp;</h2>Many people, even those with high health literacy, are confused about different <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787362" target="_blank" rel="noopener">out-of-pocket costs</a> not covered by health insurance. These can include:&nbsp;<ul>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="2" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="1" data-aria-level="1">Copay: Amount for each service, such as a doctor visit or prescription; for example, $30 for primary care, $50 for a specialist, and $250 for the emergency department.&nbsp;</li>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="2" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="2" data-aria-level="1">Deductible: Amount for medical care before insurance pays, for example, $6,000 for an individual or $17,000 for a family.&nbsp;</li>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="2" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="3" data-aria-level="1">Coinsurance: Percentage of cost a patient pays for a service that insurance covers, for example, patient pays 20% and insurance pays 80%. This cost does not apply to all plans.&nbsp;</li>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="2" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="4" data-aria-level="1">Self-pay: Travel, food, and lodging associated with cancer care: generally not covered, but there are a few exceptions, such as transplant.&nbsp;</li>
</ul>Patients routinely ask about coverage for durable medical equipment (DME). Most plans cover medically necessary items such as crutches, wheelchairs, and walkers, if submitted with the appropriate clinical documentation. However, DME coverage is on a case-by-case basis depending on the plan.&nbsp;&nbsp;Patients also frequently ask about prescription drugs coverage. For most plans, this is based on a tiered list, for example:&nbsp;<ul>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="5" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":1080,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="1" data-aria-level="1">Tier 1: Least expensive; often generic drugs&nbsp;</li>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="5" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":1080,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="1" data-aria-level="1">Tier 2: Higher-priced generic and lower-priced brand name drugs&nbsp;</li>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="5" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":1080,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="1" data-aria-level="1">Tier 3: Primarily higher-priced brand name drugs&nbsp;</li>
<li data-leveltext="&#61623;" data-font="Symbol" data-listid="5" data-list-defn-props='{"335552541":1,"335559684":-2,"335559685":1080,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"&#61623;","469777815":"hybridMultilevel"}' aria-setsize="-1" data-aria-posinset="1" data-aria-level="1">Tier 4: Highest-priced drugs&nbsp;</li>
</ul><h2>If patients have questions about their insurance or drug coverage, whom should they ask?&nbsp;</h2>Find out if your cancer center has insurance content on its website. For example, <a href="https://moffitt.org/patient-family/insurance-financial-information/insurance-coverage/" target="_blank" rel="noopener">Moffitt Cancer Center</a> provides a robust, interactive insurance webpage to proactively help patients navigate the financial landscape. Content includes lists of managed care organizations, the health insurance exchange, and Medicare coverage. Consolidated Omnibus Budget Reconciliation Act (COBRA) is just one of many terms in their glossary. Moffitt also provides a list of questions patients should ask their insurance company as well as information about financial assistance.&nbsp;&nbsp;In addition, most cancer centers have a financial counselor (or advocate) who will explain to patients their plan&rsquo;s coverage and personal financial responsibility. If the patient will participate in a clinical trial, then the patient needs to demonstrate a clear understanding of their financial costs during the informed consent process.&nbsp;&nbsp;Finally, patients can contact their insurance company&rsquo;s customer service department. This number is usually located on the back of their insurance card. Nurses should instruct patients and caregivers to keep a call log, noting the date and time of the call, with whom they spoke, and a reference number for the call. They should also include a summary of the conversation and any coverage information they obtained from the representative.&nbsp;<h2>If cancer survivors or caregivers do call the insurance number on the back of their card, what are some tips for quickly connecting to a live person?&nbsp;</h2>Most calls start by requesting the patient&rsquo;s member ID number and date of birth. As soon as able, the patient should select or say &ldquo;representative&rdquo; or &ldquo;customer service&rdquo; (depending on the options). Some plans also offer a plan advisor who works only with a specific employer group. This option is like a concierge customer service representative. If this service is available, the patient will be connected to a dedicated representative who will likely remain their contact point for any future needs. Encourage patients to note the person&rsquo;s name, contact information, and business hours. For example, if the patient lives in the Central time zone, but the representative is on the East Coast, it is helpful to know when they end their day to eliminate frustration.&nbsp;&nbsp;Oncology nurses are the &ldquo;glue&rdquo; that connects patients with their appropriate resources. They help patients find their voice with many issues, including health care coverage.&nbsp;&nbsp;This article is written by a mentee of beyond Oncology&rsquo;s Writing Mentorship Program. beyond Oncology pairs oncology nurses with writing and publishing experience (mentors) with nurses who want guidance in having their voices heard through online writing (mentees). To learn more about the program, please visit <a href="https://beyondoncology.com/be-mentored-2/" target="_blank" rel="noopener">beyond Oncology</a>.&nbsp;References&nbsp;<a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787362" target="_blank" rel="noopener">Out-of-Pocket Costs Among Patients With a Cancer Diagnosis Enrolled in High-Deductible Health Plans vs Traditional Insurance</a>&nbsp;<a href="https://moffitt.org/patient-family/insurance-financial-information/insurance-coverage/" target="_blank" rel="noopener">Moffitt Cancer Center: Insurance Coverage</a>&nbsp;

Helping Survivors of Cancer Understand the Nuances of Healthcare Coverage

Best Practices

This list of frequently asked questions can help you aid your patients in navigating insurance complexities.