In the United States, insurance provides access to health care. For example, it can cover or offset the costs of cancer care.
Most people get health insurance in one of 2 ways:
Through an employer
Through a government program. Government health insurance options include Medicare and Medicaid.
But some people do not receive health insurance at work. Others are not eligible for Medicare or Medicaid.
If this is your situation, visit www.HealthCare.gov. The website will outline options for purchasing health insurance. Or call 800-318-2596 (TTY: 855-889-4325).
These options are available because of the 2010 Patient Protection and Affordable Care Act (ACA). The legislation also changed US health care insurance coverage rules. Learn more about the Affordable Care Act and Cancer.
Types of private health insurance
Out-of-pocket medical costs will depend on your insurance type. This glossary may help you explore the following insurance types.
Private health insurance
Private health insurers use different care models.
Two common types are:
Health maintenance organizations (HMOs)
Preferred provider organizations (PPOs)
HMO. This type covers costs within a network of contracted health care providers. People choose a primary care doctor within the network. That doctor oversees a person's health. And he or she refers the person to specialists when needed.
HMOs often have the lowest patient costs for private health insurance. But HMOs generally limit coverage in these ways:
You have fewer choices of doctors and hospitals. Only doctors and hospitals contracted with the HMO are covered under the plan. But insurance companies may make exceptions for emergencies and medical necessity.
Access to a specialist requires a referral from your primary care doctor.
You may need precertification for some services, such as non-emergency hospital visits and some specialist care. Precertification means getting the HMO’s approval before receiving care. HMOs also may require notification within 24 hours of emergency care.
Some types of services may not be covered.
PPO. This model contracts health care providers to provide services at a reduced fee. Providers include doctors, hospitals, and other health care professionals. PPOs typically have a larger pool of in-network doctors than HMOs.
Most medical costs are covered when visiting in-network doctors. You only pay a small set fee. This is called a co-payment or co-pay. Also, PPOs allow visits to any doctor without a referral. PPOs may provide freedom to visit out-of-network doctors. But you may pay a larger portion of the bill.
Potential PPO restrictions:
You may need precertification for some types of care. That is more likely with out-of-network care.
Some types of service may not be covered.
Flexible Savings Accounts (FSAs) and Health Savings Accounts (HSAs) are 2 types of special bank accounts. They help you plan for medical expenses and receive tax benefits. Many employers offer these through private health insurance plans.
FSAs. You reserve a portion of your paycheck throughout the year. It is pre-tax money to use for out-of-pocket medical expenses. You decide the amount based on your estimated annual expenses.
Some plans provide an FSA debit card. For others, you pay first and submit your receipts for reimbursement. At the year end, any unused funds will be lost.
HSAs. The funds you put in an HSA do not expire. Unused funds remain in your account for the next year. Additionally, you may keep the account after leaving a job. You also have the option to invest the money. But only high-deductible health insurance plans offer HSAs.
With a high-deductible health plan, you are responsible for 100% of costs until meeting a deductible. Usually, this deductible is several thousand dollars. After you reach this amount, your insurance will pay 100% of covered medical services. You start with a new deductible each year.
Government-sponsored insurance programs
Medicare. Medicare is the federal health insurance program. It covers people 65 and older and some disabled Americans. It has different parts.
Medicare Part A covers these costs:
Skilled nursing care
Some home care services
Medicare Part B covers these costs:
Physical and occupational therapy
Many cancer drugs given in outpatient medical offices and clinics
Selected supplies that are deemed “medically necessary”
You are not required to enroll in Part B. But if you enroll later, you may face a late-enrollment fee.
Medicare Part C is also called Medicare Advantage. It allows Medicare-approved companies to provide Part A and B benefits. Sometimes, Medicare Advantage plans include Part D benefits.
Medicare Part D is a voluntary prescription drug benefit. It covers prescription drugs not otherwise covered under Medicare Parts A or B.
Medicare does not cover all health care expenses. As a result, some people purchase supplemental insurance policies. These may be private insurance products called “Medigap” policies.
Medicaid. The federal and state governments both fund Medicaid. Each state operates its own program. This means eligibility and services vary by state.
Traditionally, Medicaid has covered low-income people who are older or have a disability. It may also cover certain people in families with dependent children.
Some states elected to expand Medicaid under the ACA. These states may provide coverage for other low-income adults.
Other types of insurance
Health insurance covers some costs of cancer care. But typically, one plan does not cover all the costs. Other types of insurance are available to cover additional expenses.
Supplemental insurance. This helps cover expenses not covered by your primary insurance. Or it may cover costs you pay within your existing plan:
Other out-of-pocket expenses
Supplemental insurance may also offer other benefits. For example, some plans cover compensation for earnings lost from missed work.
Disability insurance. This replaces income lost if health issues keep you from working. Qualifying health issues include long-term illnesses and injuries. Typically, employers and government-sponsored programs provide disability insurance. But individual policies are also available.
Hospital indemnity insurance. This provides limited coverage for hospital stays. It is usually a fixed amount for each day. And it is usually capped at a maximum length of stay. This particularly benefits people with a basic insurance plan that limits coverage of hospital care.
Long-term care insurance. This provides coverage to offset costs of long-term care. For example, it may include nursing home care. Most private insurance plans and Medicare provide limited long-term care coverage.
Insurance in practice
It is important to understand an insurance plan’s benefits and limitations. The following examples illustrate how co-pays, co-insurance, and deductibles work. You should also talk with a representative of your insurance provider. He or she can explain the details of your specific plan.
Example #1: Co-pays
Anna needs to see 2 specialists this week. Dr. Martinez charges $100 per visit. Meanwhile, Dr. Jones charges $500 per visit. Anna’s insurance requires her to pay a $20 co-pay to visit a specialist. How much will the doctors charge her for the appointments?
Answer: Anna's out-of-pocket costs will be $20 for each appointment. That is a total of $40. Co-payments are a set amount. And this means Anna’s payment does not depend on the bill amount.
Example #2: Co-insurance
Martin needs to see 2 specialists this week. Dr. Andrews charges $100 per visit. Meanwhile, Dr. Lee charges $500 per visit. Martin’s insurance requires a 20% co-insurance for specialist visits. How much will the doctor’s charge him for the appointments?
Answer: Martin will pay Dr. Andrews $20. He will pay Dr. Lee $100.
A co-insurance payment is calculated by multiplying each bill by the co-insurance percentage.
Dr. Andrews will charge Martin $20 because $100 x 20% = $20.
Dr. Adams will charge Martin $100 because $500 x 20% = $100.
Example #3: Co-insurance and deductibles
Jasmine has a deductible of $2,000 a year. And she has not incurred any medical costs yet this year. Her co-insurance for a hospital visit is 20%. She recently had a surgery that cost $10,000. How much will she need to pay?
Answer: Jasmine will pay $3,600 out of pocket for her procedure. The steps below explain how:
STEP ONE. Subtract the deductible from the total bill: $10,000 – $2,000 = $8,000.
STEP TWO. Multiply the difference by the co-insurance percentage: $8,000 x 20% = $1,600. This gives Jasmine’s co-insurance amount.
STEP THREE. Add the deductible and the co-insurance amounts. $2,000 + $1,600 = $3,600.
What happens if Jasmine has another identical surgery within the same year? She already paid her deductible. Thus, she would have only the co-insurance payment. That would be $2,000 because $10,000 x 20% = $2,000.
Some medical expenses not covered by insurance can be deducted from federal income taxes.
Examples of potentially tax-deductible expenses are:
Mileage for trips to and from appointments
Meals during lengthy medical visits
A tax advisor can explain rules about medical expense deductions.