Medicare is public health insurance funded by the federal government. To qualify for Medicare an individual must be a U.S. citizen or a legal resident for at least five consecutive years and meet one of the eligibility requirements listed below.

Who is eligible for Medicare?

• Individuals 65 years old or older
• Individuals younger than age 65 who have been entitled to receive Social Security Disability Insurance (SSDI) benefits for 24 months
• Individuals with Amyotrophic Lateral Sclerosis (ALS) or End-Stage Renal Disease

There are four parts of Medicare (A, B, C, and D):

Part A is hospital insurance. Part A coverage primarily applies to hospital stays and inpatient care. For most individuals there is no premium for Part A. This is because working individuals often pay into the Medicare system through a Medicare tax and that tax serves as the Part A premium as long as the individual has paid into the system for a qualified period of time.

Part B is medical insurance. Part B coverage primarily applies to outpatient care. Coverage also includes laboratory services and medical equipment. It does not cover vision or dental care. There is a monthly premium for Part B that individuals must pay when they become eligible for Medicare. The monthly premium is determined based on the income reported on an individual’s most recent federal tax return and the amount can change each year. In 2024, single individuals who report income of $103,000 or less, or a married couple reporting $206,000 or less, on their 2022 tax return will pay approximately $174.70 per month in premiums.

• Part B only covers 80% of outpatient care costs. The remaining 20% must be paid either out-out-pocket by the enrollee, or through a Medigap policy.
• Medigap is a type of supplemental insurance to Medicare which can help cover costs not covered by Medicare Part B.
  • Medigap policies are offered by various health insurance companies at different rates and with different levels of coverage.
    It is important for an individual to select a policy best suited to their medical needs.
  • Medigap policies do not cover prescription drugs, and enrollees are still responsible for out-of-pocket costs associated with Medicare Part D prescription drug coverage.

Part C is known as Medicare Advantage. Medicare Advantage is a health plan offered by a private party approved by Medicare. Common Medicare Advantage plans include health maintenance organizations (HMOs), which restrict enrollees to health care providers in the plan’s network, and preferred provider organizations (PPOs), which allow enrollees to visit providers outside of the network, although the provider must agree and there may be a higher cost for treatment.

• Medicare Advantage Plans offer an alternative to Medicare Parts A and B, and typically bundle the coverage offered through Medicare Parts A, B, and D.
  • Medicare Advantage Plans may feature lower premiums and lower total out-of-pocket costs than Medicare Part B, as well as additional coverage such as dental or hearing services.
  • It is important to understand what type of Medicare Advantage Plan you have and make sure the providers you need to see are covered by the selected plan’s network.
  • Medicare Advantage enrollees cannot also have a Medigap policy. This is because most Medicare Advantage Plans will either cover the 20% of medical cost not covered by Medicare Part B, if the enrollee is required to be enrolled in Part B or cover the entire medical cost 100% in exchange for a higher premium.
  • Most Medicare Advantage Plans include prescription drug coverage, which eliminates the need for Medicare Advantage enrollees to purchase a Part D prescription plan.
  • There can be copays with a Medicare Advantage plan.
  • If a service is not covered under the Medicare Advantage Plan, covering it with a Medigap policy is not allowed.

Part D provides prescription drug coverage. There is a monthly premium for Part D that is determined based on the Part D prescription drug plan selected.

• Monthly premiums can change each year and will be higher for enrollees with higher incomes.
• For 2024, the Centers for Medicare & Medicaid Services (CMS) estimates that the average monthly premium will be approximately $55.50 for individuals reporting income of $103,000 or less and couples reporting income of $206,000 or less on their 2022 tax return.
• Individuals may choose not to include Part D if they feel they do not need prescription drug coverage; however, if they choose to enroll later, they can incur a penalty by having to pay a higher premium.

What is the overall cost of Medicare?

There is not a set rate that individuals pay for Medicare. The overall cost depends on the plan(s) that individuals select based on their needs and, in some cases, on enrollees’ income.

The overall cost of Medicare can potentially be lowered through benefits from Medicare Savings Programs, designed for individuals with limited income and limited assets.

• The level of benefit offered and income and asset limits vary for each program.
  • The program can help pay the premiums for Parts A (if any) and B and might also pay Part A and Part B deductibles, copays, and coinsurance.
• The Michigan Department of Health & Human Services (MDHHS) sets the requirements for the Medicare Savings Programs offered by the State of Michigan.
  • To enroll in a Medicare Savings Program Michigan residents can apply online through the MI Bridges website, or they can visit their local MDHHS office to apply in person.
  • If an individual is dually eligible for both Medicare and Medicaid, their Part B premiums, copays, and drug costs can be covered by Medicaid

When do I enroll in Medicare?

Initial Enrollment Period – Eligible individuals can enroll in Medicare Parts A and B when they turn 65. This is referred to as the Initial Enrollment Period.

• The Initial Enrollment Period begins three months before the month you turn 65 and it ends three months after the month you turn 65, so the total Initial Enrollment Period lasts for seven months.
• The month that your coverage begins depends on when you sign up, but coverage always begins on the first of the month.
  • If you sign up before the month you turn 65, then coverage will begin the month you turn 65.
• If you do not enroll in Medicare Parts A and B in the Initial Enrollment Period then you may face late enrollment penalties through a higher monthly premium.

Special Enrollment Periods – After the Initial Enrollment Period, Medicare enrollees can add, drop, or switch Medicare coverage at certain times during additional Special Enrollment Periods, or in response to certain life situations, such as moving, losing or changing your current coverage, or getting Medicaid.

• These Special Enrollment Periods may allow an individual to enroll in Medicare after missing the Initial Enrollment Period and avoid a monthly late enrollment fee or penalty.
• Before enrolling in Medicare Parts C or D, you may first have to be enrolled in Part A or Part B.
• The Open Enrollment Period for Parts C and D is October 15 to December 7 each year.
  • During this time, you can enroll in or drop Medicare Parts C or D. You can also elect to return to “original Medicare” from a Medicare Part C plan during this time.

Information about the different enrollment periods for Parts C and D can be found on the official Medicare website.

How do I enroll in Medicare?

To enroll in Medicare, you can contact the Social Security Administration over the phone or by visiting ssa.gov.

For individuals receiving Social Security Disability Insurance (SSDI) benefits, your application for benefits serves as your application for Medicare.

• Once you have been entitled to receive SSDI benefit payments for 24 months, you will automatically be eligible for Part A and Part B coverage.
• If you are enrolled in Medicare Parts A and B based on receiving SSDI for 24 months, you will also need to either enroll in Part C (Medicare Advantage) or Part D (prescription drug coverage) in order to have comprehensive health coverage.
• You can enroll in Medicare Parts C and D on Medicare.gov.
  • You will need to have your Medicare number and your Part A and Part B coverage start dates. You will then need to contact the plan you want to join, either online or by phone to complete the enrollment paperwork. Afterwards you will contact Medicare to ensure that your enrollment was processed.

What if I am still working at age 65 and have health insurance through my employer?

If you are working when you become eligible for Medicare at age 65, then you will want to understand your Coordination of Benefits (COB).

• The COB determines the order of responsibility in paying for your health insurance benefits.
• A discussion with your employer will allow you to determine which health insurance is your primary insurance.
• Typically, employers prefer to have Medicare listed as your primary insurance and employer-provided health insurance as your secondary insurance. This reduces the cost for your employer since the government will be paying for your primary health insurance costs and your employer provided health insurance can cover any remaining costs as necessary.
• Additional information about Coordination of Benefits is available from the Centers for Medicare and Medicaid Services at CMS.gov.

Additional information about Medicare is available from the following sources:

• The Medicare website (Medicare.gov) includes information about Medicare, Medigap and prescription drug plans, and resources to find care providers
• The US Department of Health and Human Services has answers to common questions about Medicare and Medicaid
• Triage Cancer – Medicare & Cancer
• The Centers for Medicare and Medicaid Services (CMS) website (CMS.gov) provides comprehensive information about Medicare enrollment and coverage

Medicaid is a government insurance program that provides free or low-cost health coverage to eligible participants, including low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is jointly funded by the federal government and the states and is administered by the states, according to federal guidelines.

Who is eligible for Medicaid in Michigan?

Michigan’s main Medicaid program for adults is known as the Healthy Michigan Plan. It is administered by the Michigan Department of Health and Human Services (MDHHS). The Healthy Michigan Plan provides comprehensive health care coverage for individuals who:

• Are 19-64 years of age
• Have income below 133% of the federal poverty level
• Do not qualify for or are not enrolled in Medicare
• Do not qualify for or are not enrolled in other Medicaid programs
• Are not pregnant at the time of application
• Are residents of the state of Michigan

Michigan Medicaid also offers several other health care programs for children and young adults, pregnant people, caretaker relatives, families, and individuals with disabilities. Each has its own eligibility criteria and benefits. Additional information about these programs is available on the MDHHS website.

What does Michigan Medicaid cover?

Medicaid covers medically necessary services, such as:

• Ambulance services
• Doctor visits
• Emergency services
• Home health care
• Hospice care
• Inpatient and outpatient hospital care
• Lab services
• Medical supplies
• Medicine prescribed by a doctor
• Non-emergency medical transportation
• Nursing home care
• Physical and occupational therapy
• Surgery

Additional services are also covered. A complete list of covered services is available on the MDHHS website.

How much do Michigan Medicaid enrollees pay for services?

Michigan Medicaid enrollees do not have to pay the full cost of covered healthcare services, but they may be required to pay a small amount as a copayment or “copay”. Copays for most Michigan Medicaid enrollees ages 21 and older are included in the MDHHS Beneficiary Copay Requirements.

Example copays include:

• Doctor’s office visit: $2
• Outpatient hospital visit: $2
• Emergency room visit: $2 for non-emergency service, free for emergency services
• Inpatient hospital stay: $50
• Pharmacy: $1 to $3
• Urgent care visit: $2

How can Michigan residents apply for Medicaid?

Applications for healthcare coverage through Michigan Medicaid are processed through the MIBridges website. MI Bridges also processes applications for other benefits, including food assistance; cash assistance; the Women, Infants & Children (WIC) program, help covering childcare costs, and help covering the cost of emergency situations.

Additional information is available on the following websites:

• Medicaid.gov
• Triage Cancer – Quick Guide to Medicaid
• Michigan Medicaid
• MI Bridges

Private health insurance coverage is provided by a private company and not the government. Insurance provided by a state government or the federal government, such as coverage provided through Medicaid or Medicare, is considered public insurance.

Several insurance terms used below (e.g., premium, deductible, coinsurance, and out-of-pocket maximum) are defined in the Understanding and Using Health Insurance section of the MI-COST website.

Common types of private health insurance plans:

• Health maintenance organization (HMO) – In HMOs, a referral from a primary care physician (PCP) is required to see specialists or other providers unless it is an emergency. HMO provider networks may be limited, and services from providers outside the network will typically not be covered; however, HMOs also tend to be less expensive than preferred provider organizations (PPOs).
• Exclusive provider organization (EPO) – EPOs may have larger provider networks than HMOs, and you may not need a referral from a PCP to see specialists, but EPOs do not cover services from out-of-network providers.
• Preferred provider organization (PPO) – PPOs tend to have large networks of providers, and enrollees can see specialists without referrals from their PCP. PPOs may partially cover services from out of network providers, but they are often more expensive than HMOs.

What do private insurance plans cover?

Private insurance plans can vary significantly in the amount of coverage they provide, and the types of care covered, but in general they help pay for a variety of healthcare services, such as:

• Medical care
• Specialist care
• Hospital services
• Rehabilitation and physical therapy
• Prescription drugs
• Mental health care

There are two main ways of obtaining private insurance coverage:

• Through an employer
• Purchasing an individual plan, such as through a health insurance Marketplace

Employer-sponsored private health insurance

Employer-sponsored health insurance is an example of group health insurance. Group health insurance plans are purchased by an employer or other organization such as a union, and then offered to employees or group members.

There are several potential advantages to employer-sponsored and other group health insurance plans.

• Lower costs to enrollees – because the risk to the insurer is spread among multiple enrollees, premiums and deductibles are often lower for group plans than for individual private insurance plans. Additionally, employers will often pay part of the premium cost, which further reduces the cost to employees or other group members.
• Supplemental coverage – In many cases, employers and other group insurers may offer supplemental coverage, such as dental, vision, or pharmacy coverage, in addition to standard medical coverage.
• Family and dependent coverage – Many group insurance plans allow enrollees to add family members or dependents to their plan for an additional cost. This additional cost is often less than if coverage was purchased independently.

The main potential disadvantage of group health coverage is that coverage is dependent on group membership. If you leave the group (e.g., change jobs), you will often lose the group health coverage.

Continuation coverage – If you lose your job, you may be able to keep your employer-sponsored group health insurance coverage temporarily. The Consolidated Omnibus Budget Reconciliation Act (COBRA) requires employers to make the same group insurance plan, with the same coverage amounts and benefits, available to employees who lose their jobs for a limited time; however, the terminated employee must pay the full cost of the coverage, including any amount the employer once contributed toward their premiums. Continuation coverage offered through COBRA can be more expensive than insurance purchased through an individual insurance plan.

If you lose your job and your employer-sponsored health insurance, consider factors such as the costs, coverage, and provider network when deciding whether to enroll in continuation coverage or to find other coverage, such as through a Marketplace plan.

Additional information about employer-sponsored insurance and other group health insurance coverage is available from the following sources:

• Forbes Advisor – What is Group Health Insurance & How Does It Work?
• Triage Cancer – Employer-sponsored Health Insurance

Individual private insurance plans

In addition to employer-sponsored or group health insurance coverage, individuals can purchase private insurance coverage either through an insurance Marketplace or directly through an insurer.

Individual private insurance – Marketplace plans

The Patient Protection and Affordable Care Act (ACA) established state health insurance “Marketplaces” where individuals and families can find and purchase coverage from private insurance companies. These Marketplaces are online portals where individuals can shop for and compare insurance plans. The Marketplaces for many states, including Michigan, are run by the federal government through healthcare.gov.

Plans certified by the ACA Marketplaces are called Qualified Health Plans. There are several important potential advantages to selecting Qualified Health Plans from an ACA Marketplace.

Essential benefits – In order to be sold through an ACA Marketplace, insurance plans must cover 10 essential health benefits:

• Ambulatory or outpatient care services
• Emergency services
• Hospitalization – including for surgery and overnight hospital stays
• Pregnancy, maternity, and newborn care
• Mental health and substance use disorder services, including counseling and psychotherapy
• Prescription drugs
• Rehabilitative and physical therapy services
• Laboratory services
• Preventive care and wellness services, including chronic disease management
• Pediatric services

The essential health benefits described above are the minimum requirements for ACA Marketplace plans. In addition, Marketplace plans must also cover birth control and breastfeeding services. The specific amount of coverage provided within each category may vary based on the specific plans, and additional state requirements. In addition to the coverage listed above, some plans may also provide additional benefits, including:

• Dental coverage
• Vision coverage
• Medical management programs (e.g., for weight management, back pain, or diabetes)

Limited cost sharing – In order to be sold on an ACA Marketplace, Qualified Health Plans must also offer limited cost sharing for enrollees. There are five different plan levels, based on the amount of coinsurance provided:

• Platinum: Insurance covers 90%, you cover 10%
• Gold: Insurance covers 80%; you cover 20%
• Silver: Insurance covers 70%; you cover 30%
• Bronze: Insurance covers 60%; you cover 40%
• Expanded Bronze: Insurance covers between 56% and 62%; you cover the remainder

Plans where the insurer pays a higher percentage of healthcare costs tend to have higher monthly premiums, but lower out-of-pocket costs for healthcare services.

Financial assistance – Based on your income, you may also qualify for financial assistance to purchase health insurance through an ACA Marketplace.

• Premium tax credits – Tax credits that lower monthly premiums are available for individuals with incomes below 400% of the federal poverty level.
• Cost-sharing subsidies – In addition to the tax credits, cost-sharing subsidies may be provided to lower the cost of deductibles and copays

Out-of-pocket maximum limits – The ACA limits the amount insured individuals can have to pay out of pocket for covered health services each year. These limits vary by plan level.

• In 2024, the maximum out of pocket costs for a Marketplace plan is $9,450 for an individual and $18,900 for a family
• Out-of-pocket maximums include money spent on deductibles, copays, and coinsurance for in-network providers, but do not include the monthly premium costs.
  • Example: If an individual paid a monthly premium of $100 ($1,200 for the year) in 2024, their out-of-pocket maximum total could be as high as $10,650 ($9,450 + $1,200)

Private insurance can be purchased directly through an insurance company and not through an ACA Marketplace, but those plans are not held to the same standards as Qualified Health Plans and do not need to meet the ACA standards for essential health benefits, cost sharing, or out-of-pocket maximum limits, and they do not qualify for tax breaks and subsidies to lower their costs.

To compare Marketplace plans and prices and apply for coverage, visit Healthcare.gov

Additional information about Marketplace plans is available from the following sources:

• Michigan Department of Insurance and Financial Services – Health Insurance Marketplace
• Healthcare.gov – What Marketplace health insurance plans cover
• USA.gov – How to get insurance through the ACA Health Insurance Marketplace
• Triage Cancer – Cancer Rights: Navigating Employment, Insurance, & Finances
• Triage Cancer – Quick Guide to Health Insurance Marketplaces

Factors to consider when selecting a health insurance plan

There are several important factors to consider when choosing a health insurance plan. Different people will make different decisions about which plan is right for them. The following questions may help you select a plan that fits your needs:

• Do you qualify for public insurance programs, such as Medicare or Medicaid?
• Can you get insurance through your employer?
• If you are considering a Marketplace plan, do you qualify for any tax breaks or subsidies?
• What medical services, including prescription drugs, are you likely to need, and how much will they cost?
  • It is important to consider a plan’s total costs, including monthly premiums, deductibles, coinsurance, and out-of-pocket maximums
• Are doctors you want to see included in the plan’s provider network?
• Does the plan cover your prescriptions and preferred pharmacies?

Selecting a health insurance plan can feel confusing, but there are resources and tools that can help.

• Triage Cancer – Picking a Health Insurance Plan
• Healthcare.gov – 3 things to know before you pick a health insurance plan

Changing insurance plans

Your insurance needs may change over time. It is important to review your coverage and your healthcare needs from time to time to determine whether your current plan is still the best fit. If you do decide you would like to make changes to your health coverage, you can do that during an annual open enrollment period, when changes to health insurance coverage can be made for any reason.

• For Marketplace plans, the open enrollment period is between November 1 and January 15
• Check with your employer to find out when the open enrollment period is for employer-sponsored health coverage
• The General Enrollment Period for Medicare is between January 1 and March 31 each year
• You can apply to enroll in Medicaid at any time

Changes to health insurance coverage can be made outside of open enrollment periods for certain qualifying life events. These include:

• Getting married
• Having a baby
• Losing other health coverage

Additional information about changing insurance plans and open enrollment periods is available from the following sources:

• Healthcare.gov – Open Enrollment Period
• Triage Cancer – Checklist: Making the Most of Employee Benefits During Open Enrollment

Health insurance coverage can be complex. Becoming familiar with some key health insurance concepts can help people with cancer gain confidence in navigating the healthcare system.

Health Insurance Terms

Below we define several terms related to health insurance that can determine how much you may pay for health care.

• Premium – the amount you pay to have health insurance coverage, whether you use it or not.
  • Premiums are typically paid monthly, either directly to the insurance provider, or through payroll deductions for employer-sponsored plans.
  • Premium amounts can vary based on the type of insurance and the level of coverage provided, as well as on other factors such as your age, location, and tobacco use.
• Deductible – the amount of money you need to pay out of pocket for covered health care services before your insurance plan begins to cover costs.
  • If your plan has a $1,000 deductible, then you would be responsible for paying all the first $1,000 toward your care and then your insurance would begin covering costs beyond that amount.
  • Deductibles can vary widely from less than $100, or even $0, to several thousand dollars.
  • Deductibles typically reset at the beginning of a new calendar year.
  • Switching insurance plans mid-year (for example, if you change jobs) will typically result in needing to start over with a new deductible for the new insurance coverage.
• Copay – the fixed amount you pay to access healthcare services after you’ve met your deductible for the year.
  • Copays vary based on the insurance plan and services being accessed.
  • A copay for a doctor’s visit might be $20 while the copay for a visit to a specialist might be $50.
  • Prescription drugs and other services, such as emergency room visits and hospital stays, could have different copay amounts.
• Coinsurance – the percentage of costs for covered health care services you are responsible for after you’ve met your deductible. This may also be called a “cost share”.
  • Coinsurance amounts are often expressed as percentages
  • An 80/20 split is a common coinsurance arrangement and means that after meeting your deductible your insurance company would pay 80% of covered medical expenses, and you would be responsible for paying the remaining 20%.
• Out-of-pocket maximum –The out-of-pocket maximum is the most you must pay for covered healthcare costs during a plan year. After you’ve spent that amount on deductibles, copays, and coinsurance for in-network, covered costs, your health plan pays the rest of the costs for covered benefits for the rest of the plan year.
  • Out-of-pocket maximums do not include monthly premiums, out-of-network costs, or anything you spend for care that your plan does not cover.

Out-of-pocket cost calculation example:

Susan has an individual insurance plan with the following benefit/fee structure:

• $1,000 deductible
• 20% coinsurance
• $5,000 out-of-pocket maximum

Susan goes in for her regular mammogram, which costs $250. Before the mammogram, Susan had not paid any medical expenses that counted toward her deductible this year, so she is responsible for the full $250 charge.

Based on her mammogram results, her doctor refers her for a PET scan, which costs $2,000. After paying $250 for the mammogram, Susan must pay the first $750 of the PET scan cost before she meets her yearly deductible of $1,000. After that, Susan’s health insurance will cover 80% of the remaining costs, and Susan is responsible for 20% coinsurance. Of the remaining $1,250 cost of the PET scan, Susan must pay 20%, or $250, and her insurance company will cover the remaining $1,000.

If Susan needed surgery based on the PET scan results and that surgery cost $30,000, Susan would be responsible for paying 20% of the cost until she hit her annual out-of-pocket maximum. Without considering the out-of-pocket maximum, she would owe $6,000 for surgery (20% coinsurance x $30,000). But since she has already paid $1,250 toward covered costs for the year ($250 for the mammogram + $1,000 for the PET scan), she only needs to pay $3,750 more to hit her out-of-pocket maximum of $5,000 for the year. After Susan pays $3,750 for the surgery and meets her out-of-pocket maximum, her insurance company will cover the remaining charges for her surgery, and all remaining charges for covered services for the rest of the year.

In-network vs. out-of-network providers

• In-network providers are those who have contracted with your insurance company to accept negotiated (often discounted) rates for healthcare services.
  • In-network providers typically provide care at lower costs to insurers they contract with, and the contracts typically require providers to accept the insurer’s payment plus any copay or coinsurance costs owed by the insured individuals as payment in full.
  • In-network providers cannot “balance bill,” a patient, or charge them the difference between the negotiated rates and the providers’ retail prices.
• Out-of-network providers are not part of an insurer’s provider network and have not agreed to accept the insurer’s negotiated prices.
  • Depending on the specific health insurance plan, services from out-of-network providers may be only partially covered or not covered at all.
  • If services from out-of-network providers are covered, they may have higher deductibles and higher (or no) out-of-pocket maximum limits.
  • Out-of-network providers will balance bill patients for any remaining charges not covered by their insurance plan.

It is important to determine whether any providers you see are part of your insurer’s provider network, and if they are covered by your specific health insurance plan. You can do this by contacting your insurer, and by asking your provider whether they accept your insurance and are in-network on your plan and for the services provided.

Pre-authorization

Your insurance company may require you to get an approval for certain types of medical care before they will cover it.

• The process of requesting approval from an insurer before providing a service or treatment can go by several names, including pre-authorization, prior authorization, or pre-approval
• Pre-authorizations are typically required for more expensive services or treatments. Your insurer may not approve a costly service until they determine it is medically necessary, or they may want you to try a less expensive medication or treatment before they will approve the more expensive version.
• Ask your healthcare provider if the care they recommend (e.g., tests, procedures, prescriptions, etc.) requires pre-authorization. They may submit a pre-authorization request for you, or they may tell you to talk to your insurance company.
• Your health insurance plan or insurer’s website should have information about which procedures, services, or prescriptions must be pre-approved to be covered
• If you receive care that requires pre-authorization before it is approved by your insurer, you could be responsible for the full price of that care

Health Insurance denials and appeals

• Denials – Sometimes health insurers will deny requests for pre-authorization or will not cover certain recommended tests, treatments, or medications. If this happens, you can ask your health care provider to help you get the care covered. They may be able to provide additional information or justification to your insurer to support the use of the prescribed care. Your care team may also be able to identify a different test or treatment that might work similarly well and be approved by your insurer.
• Appeals – You have the right to appeal your insurance company’s decision to deny coverage. If your insurance company denies a claim or ends your coverage, they must let you know why, and how you can appeal their decision.
  • There are two ways to appeal an insurer’s decision to deny a claim or coverage:
    • Internal appeal – You can ask your insurer to conduct a full and fair review of its decision. If the denied care or service is needed urgently, the insurer must conduct this process quickly.
    • External review – You have the right to have your appeal reviewed by an independent third party. In an external review the insurance company does not get the final say over whether to pay the claim.
  • Additional information about your rights and how to file an internal appeal or external review is available from Healthcare.gov.

Additional information about understanding and using health insurance is available from the following sources:

• Triage Cancer – Cancer & Health Insurance
• Healthcare.gov – How insurance companies set health premiums
• Healthcare.gov – How to appeal a denial