Medical Insurance Coverage for Prostate Cancer

Understanding the benefits provided by your medical insurance is critical as you explore the possible tests and treatments for prostateThe prostate is a walnut-sized gland located between the bla... Full Definition cancerCancer is a group of diseases where cells grow abnormally an... Full Definition. Whether you have private insurance such as a Health Maintenance Organization (HMO), a Preferred Provider Organization (PPO), a government-sponsored insurance program like Medicare or Medicaid, insurance from the Health Insurance Marketplace also known as an exchange, or Department of Veterans Affairs Health Benefits (TRICARE), you may want to request a case manager from your provider to help you navigate your coverage. Keep in mind that the type of insurance you have may impact the amount of out-of-pocket costs you pay during treatment and through recovery.

While health insurance covers many of the costs of cancer care, there are other types of insurance that may help pay for other associated expenses. These include Supplemental Insurance, Disability Insurance, Hospital Indemnity Insurance, and Long Term Care Insurance. You may want to speak with your insurance agent about your eligibility for these and other programs.

Coverage for Screening Options

While the American Cancer Society (ACS) does not recommend routine testing for prostate cancer for all men, the ACS does support legislation ensuring men have insurance coverage for prostate cancer screening exams. The two most common screening tests are prostate-specific antigen (PSA) testing (a blood test) and digital rectal exam (DRE). Your doctors and other healthcare providers should offer information on the potential risks and benefits of these tests.

Many states provide coverage for annual testing for men, age 50 and over, and for high-risk men, age 40 and over. In terms of prostate cancer, high risk refers to African American men and/or men with a family history of the disease. Some states have slightly different coverage requirements; check with your insurance provider or with your state insurance commissioner’s office to see what’s covered.

At this time Medicare covers the PSA and DRE once a year for all men with Medicare age 50 and over. There is no co-insurance and no Part B deductible for the PSA test. For other services, the beneficiary would pay 20 percent of the Medicare-approved amount after the yearly Part B deductible.

Medical recommendations for care, insurer coverage for tests and laws on coverage vary from state to state and may change, so check with your insurer or with your state insurance commissioner’s office to see what’s covered.

Coverage for Prostate Cancer Treatments

Prostate cancer is a complicated disease that usually consists of multiple cancerous lesions in the prostate. Many patients live long and healthy lives with a prostate cancer diagnosis. However, the anatomical region where the prostate is located poses a challenge for therapy and there are significant side effects like incontinence or erectile dysfunction that can decrease quality of life. For these reasons, the treatment goal for prostate cancer involves striking a balance between targeting the largest lesion that is driving the disease and minimizing treatment complications in order for the patient to maintain quality of life. Most health insurance policies cover standard approved treatments for prostate cancer. However, there are valid emerging treatments available that insurance will not automatically cover. If you are interested in such a treatment, you may have to put some extra effort into getting it covered.

How to increase your chances for coverage if you think the testing or treatment may be denied.

Take time to fully understand your health insurance plan before you begin treatment. This will help you to avoid surprises once you’ve started treatment. Here are some steps to take:

1. Obtain an updated, complete copy of your health plan (sometimes known as the Summary Plan Description).
2. Ask questions. Talk with your employer’s health benefits department. Call your health plan’s customer service line. Ask about any policies not included in the benefit book, such as appeal processes and how denials are formulated. Explore what legal health insurance requirements your state mandates.
3. Get a letter of referral from your physician that clearly indicates that he or she strongly recommends a particular treatment.
4. If coverage is an issue with your HMO, consider switching to a PPO plan with the same provider. The best time to make the change is during “open enrollment” or at policy renewal time.
5. Shop around for other insurance companies and switch to a provider that is known for approving the treatment being recommended. However, be careful not to cancel your original coverage until the new coverage takes effect.

What happens if you are denied coverage?

1. You will receive a letter if your request is denied or pended. Health plans are required to state the exact reasons for the denial and provide an opportunity to discuss the denial with the reviewer.
2. Whenever you communicate with the insurance company, take careful notes.
3. Document every phone call you make, as well as those you receive. Note the date and time, and get the name and position of anyone with whom you have spoken. Keep copies of all written communication that you send to the insurance company, hospitals, and doctors. Save copies of anything sent to you.

If your coverage is denied, follow these steps to appeal your case:

1. Ask your health plan which guidelines they used to formulate the denial.
2. Submit documentation clearly stating the reason for the requested service. Health plans make their coverage decisions based on the documentation you provide, so it’s in your best interest to provide complete information up front. Print out any information that supports your position. Keep copies of all medical documentation. In many cases, your physician can provide the medical documentation you need. Your physician can also discuss the denial with your health plan’s physician reviewer.
3. You can also ask your doctor to appeal to the insurance company directly. Sometimes the insurance company needs very specific medical details to approve a test or treatment.
4. Follow up with your health plan if it hasn’t responded in a timely manner.
5. If your appeal is not overturned on the first try, request a second appeal. Most plans also provide a third level of appeal. If all levels of appeal are overturned, consider filing with an independent review board or the insurance commissioner. At this point, you may require a lawyer. Be persistent, factual, and adhere to all requests and requirements of the health plan.
6. Do not bypass any step in the appeal process. If your first-level appeal is denied, do not jump right to an independent reviewer. Some insurance regulations and even some independent review boards require that the policyholder first file an internal appeal with the insurance carrier. This is a prerequisite to getting an outside agency or, in some cases, winning in court.

While this process may seem like a lot of work, it is absolutely worth it if it means you can choose the care option that is best for you. Work with your doctor to find and fund the best treatment you possibly can.