Health insurance can be complicated, and it is common to be confused about the details. Read on for information about terms you may hear, the different types of insurance available, options for young adults, and coverage for genetic testing.
Understanding insurance terminology
Some terms you will hear from your insurance company:
- Co-payment – the amount that you must pay at the time of the service, such as the doctor’s visit for treatment. This is usually a set fee.
- Deductible – the amount of money that you must pay each year before the insurance company will intervene on the payments. Once you have reached your deductible, the insurance company will begin to cover payments.
- Co-insurance – the certain percentage of the bill that you are required to pay even if you have met your deductible.
- Premium – the amount paid to a health insurance company for your coverage. Premiums are often paid in part or in full by you or your employer at regular intervals throughout the year.
Types of health insurance plans
If the doctor that you are seeing accepts your insurance company, the doctor’s office will most likely bill the insurance company for you, allowing you to avoid that process. Once you meet your deductible, the insurance company will begin to cover a percentage of your bills. The percentage is based on UCR (usual, customary, and reasonable) charges.
Managed care plans “manage” the healthcare of enrollees. Most managed care plans have low co-pays and low premiums. Some of these plans require that you use a set provider who coordinates all patient care. In other words, if you needed to have an appointment with a foot specialist for a problem with your foot, your primary care provider would have to give you a referral. If you do not receive a referral, your insurance plan may not cover the cost of visiting the foot specialist. There are a few types of managed care plans:
- Health maintenance organizations (HMOs): HMOs cover most expenses, but will often require you to be seen by a provider in their approved provider network.
- Point of service plans (POS): These plans are a type of HMO. They differ in that if your doctor refers you to a doctor not within the approved provider network, the plan will most likely still cover the visit. With point of service plans, you will often have to pay a percentage of the bill if you visit a doctor outside of your network and you were not referred by your doctor.
- Preferred provider organizations (PPO): This type of plan is a mixture of both HMOs and fee for service plan. With this type of plan, when you use a doctor covered by the network, the insurance plan will cover most of the bill. If you choose to see a doctor outside of the network, you will pay more out of pocket.
Fee for service plans offer you the most range when choosing a doctor and they tend to be the least restrictive. With this type of coverage, you are eligible to change doctors at any time and still remain covered. You will pay a premium as well as covering the cost of a deductible. With this type of coverage, you may have to pay the full amount, fill out forms, and be reimbursed by your insurance company.
Insurance for young adults
The passage of the Affordable Care Act (ACA) allows anyone under the age of 26 to remain on their parents’ insurance plan even if they are married, in school, live away from home or are not otherwise financially dependent on their parents. Additionally, the ACA abolished annual and lifetime limits, meaning the insurance companies can no longer limit the amount they will spend on your covered benefits. It also prohibits discrimination based on pre-existing conditions, so insurance companies cannot charge you more or treat you differently because you have or had ovarian cancer.
Insurance coverage for genetic testing
Genetic testing can help you better understand your risk for other non-gynecologic cancers as well the risk for your family members. Issues of coverage, privacy and next steps can be complicated for you or your family. Genetic tests can provide you with a lot of information about future choices you might need to make. This can bring up a lot of questions about how to absorb and process new information about potential health threats. Be sure to consult a certified genetic counselor before undergoing any testing. You may want to include a family member or a friend when discussing your options. Many hospitals have genetic counselors on staff to help you understand the risks and benefits of testing.
Currently, there are no state or federal laws that mandate health insurance companies cover the cost of genetic testing to detect mutations or disorders. However, recommendations under the Affordable Care Act designate women at high risk for certain cancers, including ovarian, should be covered, along with new guidance from 2015 that women diagnosed with ovarian cancer have access to genetic counseling and testing. Because different health plans have varying coverage levels, it is important to talk to your health insurance company to find out what is covered and what your financial responsibility would be should you decide to get genetic testing. Genetic tests can cost thousands of dollars, so you’ll want to have this conversation before any tests are done.
The preventive services of genetic counseling and testing covered under the Affordable Care Act are based on recommendations from the United States Preventive Services Task Force (USPSTF) and the Department of Health and Human Services, Labor and Treasury, and include women with the following risk factors:
- Women who have been previously diagnosed with ovarian cancer
- Ashkenazi Jewish women with one first degree relative or two second degree relatives on the same side of the family with breast or ovarian cancer
- Non-Ashkenazi Jewish women who have:
- two first-degree relatives who had breast cancer; at least one of these two were diagnosed before age 50;
- three or more first- or second-degree relatives with breast cancer regardless of age at diagnosis;
- a combination of both breast and ovarian cancer among first- and second-degree relatives;
- a first-degree relative with bilateral breast cancer;
- a combination of two or more first- or second- degree relatives with ovarian cancer, regardless of age at diagnosis;
- a first- or second- degree relative with both breast and ovarian cancer at any age; or
- a history of breast cancer in a male relative
The Genetic Information Nondiscrimination Act (GINA) of 2008 is a law that protects the privacy of your family health history, genetic test results, genetic counseling information and your participating genetic research. This means it is illegal for your employer to ask or consider your genetic history in any employment matter. It is also illegal for your health insurance company to use any or your genetic information or your family’s genetic information against you in their terms of coverage.