For people who do not have health insurance through an employer or are not yet eligible for Medicare, there is still time to enroll in a plan through the Affordable Care Act (ACA) marketplace.
In most states, the clock is ticking. The open enrollment period for 2023 health plans began November 1 and ends in just 4 days, on January 15. But some states, including California, New Jersey, New York, and Massachusetts, as well as Washington, DC, have granted potential enrollees more wiggle room and have extended deadlines to the end of the month. After that, persons in special circumstances, such as those who have lost coverage or who have very low income, may qualify for special enrollment.
Currently, almost 16 million Americans have signed up for health insurance through the ACA, but millions still remain uninsured.
During the enrollment period, individuals can select a major health insurance plan or an ACA-compliant health insurance plan, and they can adjust or cancel their existing insurance plans.
But navigating the health plan options, especially for people with cancer and other complex, chronic conditions, can be a daunting, confusing experience.
“When picking a health insurance plan, there are a few key considerations,” explained Stacie B. Dusetzina, PhD, professor of health policy, Ingram Professor of Cancer Research, Vanderbilt University School of Medicine, Nashville, Tennessee.
The bottom line is finding the right balance of the scope of care and covered costs. The most obvious cost consideration is the premium — what a person can expect to pay every month to participate in the plan. But other cost considerations — what a person can expect to pay when they need treatment — can be even more important. These costs include a plan’s deductibles, copayments, coinsurance, and out-of-pocket maximums.
Such considerations are important for patients with cancer, who often require expensive therapies as well as ongoing medical services and surveillance — some of which can come to tens of thousands a month.
Dusetzina and other experts outline some key guardrails for how people with a history of cancer can pick the best plan for them.
Step 1: Choosing a Metal Plan
The first consideration when choosing a health plan through the ACA exchange is what metal category a person wants. Insurance plans are divided into four “metal” categories: bronze, silver, gold, and platinum. These categories differ by how costs are shared between the patient and the payer.
Bronze plans offer the lowest monthly premium but have the highest costs when patients need care. With bronze plans, an insurer will pay about 60% of the overall cost of care, leaving the consumer on the hook for the remaining 40%.
At the other end of the spectrum are platinum plans, which have the highest monthly premium but require patients to shell out the least amount of money when they need care. With platinum coverage, the insurance company typically covers 90% of the bill.
It pays to look carefully at individual plans. For example, while silver plans have higher premiums than bronze, deductibles through silver plans are usually lower, which may save a person money in the long run.
“I want to emphasize that for patients with cancer or survivors, we encourage them not to only focus on the premiums,” said Anna Schwamlein Howard, policy principal at the American Cancer Society Cancer Action Network Cancer. “A plan with higher premiums may end up being more cost-effective once you take into account all expenses [and subsidies].”
Notably, millions of Americans may be able to get steep discounts on an ACA plan. According to the Kaiser Family Foundation, about 5 million uninsured Americans are eligible for silver plans that have no or almost no premium. Under the Inflation Reduction Act, people with silver plans may also be eligible for cost-sharing subsidies, which can further reduce out-of-pocket expenses.
“Silver plans may look more expensive than bronze plans when you are shopping, but you may qualify for discounts for the silver plans that make them a better overall deal,” said Dusetzina.
Step 2. Navigating the Scope of Care
Beyond metal tier, the other big consideration, Dusetzina noted, is the plan type.
The plan type dictates the health systems and doctors you have access to — who is considered “in network” — as well as the extent a plan will pay for care from an out-of-network provider. The most common types of health insurance plans are preferred provider organizations (PPOs), health maintenance organizations (HMOs), high deductible health plans, and point of service plans.
Although PPOs typically come with the highest premiums, this type of plan offers the most flexibility in terms of provider selection and scope of care. HMOs, on the other hand, come with much lower premiums but are far more restrictive in scope. HMOs, for instance, usually don’t cover out-of-network care. In fact, some plans have no out-of-pocket maximums for out-of-network care, which means patients would need to pay all of these expenses.
In addition, HMO plans require that patients have a primary care provider to coordinate all their specialty care, which could delay time-sensitive care for those with cancer.
“For people with cancer or with a history of cancer, it is really important to make sure you have access to specialists,” Dusetzina said. “If there is a great cancer center in your area, for example, you might want to make sure they are covered by the health plan network. If they aren’t covered by your plan, you could be exposed to very high costs if you need to see them in the future.”
Step 3. Understanding What’s Covered
It’s also essential to know what specific services and prescription drugs are covered in each individual plan. The services and drugs included can vary not only by plan type — PPO vs HMO — but also within plan types.
First, understand the extent of coverage for medical emergencies and frequently used services — both are important factors for those with cancer. Research shows, for instance, that emergency department (ED) visits are on the rise among patients with cancer, often for unforeseen pain, breathing problems, bleeding, or gastrointestinal problems. Patient with cancer who require emergency care may be on the hook for thousands of dollars in ED fees.
“If you don’t have that amount available in savings in case of an emergency, you should see if there are plans with slightly higher monthly premiums but lower out-of-pocket costs for emergency care,” said Dusetzina.
As for frequently used services, patients with cancer often need numerous prescription drugs in addition to their anticancer therapies.
“Some plans require deductibles on prescription drugs, and some don’t,” she said. “You also want to make sure any medications you are already taking are covered by the health plan you pick. This can help you avoid needing to switch medications or having to deal with very high costs or treatment interruptions.”
To prevent coverage issues, Howard suggests that patients make a list of their current medications and then look at the formulary for the different plans. “That will tell you what they cover and the expected out-of-pocket expenses.”
The same is true for a patient’s physicians and care facilities. “It can help make the choice easier if you take the time to review which providers are in the network and if you are getting treatment at a specialized facility — if that is included in the network,” said Howard.
Taking a closer look at what each plan offers will allow patients to make a more informed choice.
“All of this information is available at Healthcare.gov,” Howard said. “I highly recommend that people call them and go through the process, and they can help you in selecting the best plan and give you information about subsidies.”
Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.
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