What role does health insurance play in cancer care?

Just as cancer care is specific to the patient, health insurance is also specific to the member. While this topic is challenging and unimaginable, we hope to provide some transparency from the member's perspective.

A health plan can often be a point of contact to connect members with critical resources during this diagnosis. Continue reading to learn more from our care management team about what healthcare coverage may look like if you or a loved one is faced with a cancer diagnosis.

Step 1: Ask questions to know what’s covered

It’s important to remember that your employer dictates your health plan, and that is what determines a member’s cost. However, health plans can work with members to identify solutions and resources when they are available. If something is denied or doesn’t work out, you can contact your health plan. A representative can explain your coverage options to help find a resolution.

Step 2: Understand costs & financial impact

For a detailed breakdown of covered services, sign in to your Member Portal to review your Summary of Benefits. “It really depends on the member’s current plan. For example, some insurance plans may cover the cost of a wig while the member will only have to pay their co-insurance for the product,” said Suzi Ribeiro-Pierre, RN at Mass General Brigham Health Plan.

She added, “Most often, members are reaching out to us about cost. The financial impact is the top concern members have concerning medications and treatment. At times, we’ll work with customer service to try and find an answer.”

Step 3: Verify your network and providers

Some providers may be in-network at one location while out-of-network at another. If possible, verify that your provider and the location you’re receiving care are both in-network before scheduling. An T. Thuy Nguyen, RN at Mass General Brigham Health Plan suggested, “Talk with your specialist first to figure out what the plan of care is. Then, ask the office to look into what's covered and what's not.”

The good news is you can check this information on your member portal. The portal will have your summary of benefits and allow you to look up doctors within your network. When you learn more about treatment or medication, you can connect with customer service for more details.

Step 4: Explore support programs & resources

“The role of a social care manager is to screen, educate, and link members with community resources that remove barriers,” said Beth Weidman, Social Care Manager at Mass General Brigham Health Plan. She added, “A common problem we see is members not knowing about available resources and how to apply for eligible benefits. We can assist with navigating the resource process.”

There’s a lot of support within the health insurance plan. Working with a case manager or social care manager can help connect members to resources, such as cancer support groups or food programs tailored to medical needs. The best-case scenario is when the health plan is on the same page as the specialist or provider. This is one way to mitigate miscommunications such as a prior authorization rejection.

For members facing a new cancer diagnosis, a social care manager can educate them about valuable resources. These resources cover the main categories of income, food, transportation, and housing. Weidman explained, “One organization that we often share resources from is the American Cancer Society. That organization can link members to support groups, possible grant options for income assistance, and transportation services, depending on location.”

At Mass General Brigham Health Plan, social care managers can link members to a Licensed Independent Clinical Social Worker at their treating hospital. These individuals have access to additional resources for patients.

Plus, social care managers can educate members about income options during a medical leave, such as:

• Paid Family and Medical Leave
• Short/long-term disability
• Emergency Aid to the Elderly, Disabled, and Children
• Community support through Tzu Chi: a global non-profit humanitarian organization founded in 1966 by a Buddhist nun

“Our goal is to minimize the stress of an already stressful time by addressing social determinants of health,” said Beth Weidman, Social Care Manager at Mass General Brigham Health Plan.

Step 5: Ask for help

As mentioned above, your health plan is available to help you if you have questions or concerns. Additionally, if you’re a Medicare Advantage member with Mass General Brigham Health Plan, a care guide can help connect you with additional resources. For example, if a Medicare Advantage member is hospitalized, they may have access to Community Servings, an at-home meal delivery service. Many members can also access transportation support for medical appointments.

Learn more about cancer care at Mass General Brigham.