Out-of-Pocket Costs for MCO Patients

What are my out-of-pocket costs under an MCO?

Generally, patients like MCOs because patients pay lower costs than they do under private health plans or public health programs such as Medicare. But there are costs. These costs include:

• Co-payments: You may have an amount that you have to pay each time you visit your physician. It might be $15 or $25. This is a co-payment — or co-pay. You may also have a co-pay when you fill a prescription. For these services, after your deductible, this is all you have to pay.
  
• Deductible: This is a big lump sum that you pay toward until it is paid every year. It can be anywhere from $100 to $5,000. This is something you need to know about your policy. HMOs generally have the lowest deductible. Single-family policies usually have the highest deductible.
  
• Coinsurance: This is the percentage of the total cost of each service that you will pay, or the division of cost between you and your insurance company. For example, if you have a 20 percent coinsurance, you pay 20 percent of what your insurance allows for certain services, and your insurance company pays the remaining 80 percent. Services that may require you to pay coinsurance include surgeries, intravenous drugs, or all services.
  
• Premium: This is what you pay to have health insurance on a monthly (or another time frame, like yearly) basis. Increasingly, employers are asking employees to pay a higher part of their premium. For cancer patients responsible for many aspects of their treatment, this payment can be a hardship. If you are responsible for any part of your premium, be sure that you pay it automatically (on a charge card or automatic withdrawal from your bank). Go to our Help with Medical Costs page for assistance if you are having trouble meeting the ever-increasing premiums.

How can I minimize my MCO out-of-pocket costs?

Sometimes, your policy is what it is and there is nothing you can do, except take the bad with the good. But if you question your charge (after reviewing your benefits), check some of these issues before you pay your bill:

• Make sure you are informed before any new cancer treatment about how much it will cost. Remember, your doctor’s office can only estimate these costs because patients react to treatments differently and may ultimately need different drugs. Radiation treatments can also vary from those in the original treatment plan. But even a ballpark estimate can provide crucial information.
  
• Coordinate your benefits with your spouse (or your domestic partner, in some areas). Make sure all of your providers — doctors and hospitals — have your spouse’s or your domestic partner’s insurance information. Your spouse’s plan — or your ex-spouse’s plan if you are separated or have this as part of your divorce decree — sometimes will pick up your out-of-pocket costs if they consider them to be medically necessary (like your own policy).
  
• Check your insurance policy for catastrophic coverage or stop losses. Catastrophic coverage refers to insurance companies paying 100 percent of your costs after a certain out-of-pocket dollar amount. While this dollar figure may sound huge ($20,000 to $50,000 or more, usually), you might pay that if you have chemotherapy, radiation therapy, and/or surgery. Be warned: Your insurance does not pay this automatically. You or your physician need to get after the insurance company to pay their share.
  
• If you really cannot pay the whole amount at once, have your cancer physician put you on a payment plan. Many of them will take a set amount from your charge card or bank account each month until your debt is paid off.
  
• If you feel as if you really cannot afford the expected amount of your costs, seek assistance. Many of the cancer product organizations have foundations that can help you if you qualify for assistance. This does not apply to every cancer patient — you must have proof of your status and the amount that is coming out of your pocket. For more information, see the Help with Medical Costs pages of this site.