Most Health Plans Cover Treatment and Related Services

In this section, you will find information about group and individual health plan coverage of:

• Cancer treatment

• Tumor biomarker testing
• Fertility preservation
   

The ACA requires most insurance plans to cover cancer treatment

Under the Patient Protection and Affordable Care Act (ACA), most group health plans, as well as policies sold in the Health Insurance Marketplace and in the small group and individual markets cover a set of essential health benefits, including cancer diagnosis and treatment.* Copays, coinsurance and deductibles may apply. Your health insurance policy ultimately determines the costs you will pay throughout cancer treatment and recovery. Coverage for specific doctors, facilities or treatments may vary based on your plan. 

*It is important to note that short-term, temporary or catastrophic coverage health plans may not cover cancer treatment and can exclude coverage based on pre-existing health conditions so it is best to avoid these health policies.

Tumor Biomarker Testing

Precision medicine in cancer treatment is driven by tumor biomarker testing. Biomarker testing may be done to determine if a tumor has certain features indicating that the cancer is more susceptible to specific treatments called targeted therapies. A tumor test can also help establish how aggressive the cancer is and whether it’s likely to recur. Most private insurance carriers cover at least some biomarker testing for patients with certain cancers who meet established medical criteria. Insurers are more likely to cover specific, limited tests versus broad profiling. Coverage varies so your oncologist should provide guidance. Many hospitals and oncology practices have nurse navigators, social workers or financial counselors who can help determine insurance coverage and identify financial assistance if needed.

Lynch syndrome

In people diagnosed with an HNPCC-associated cancer, testing for Lynch syndrome often begins with tumor testing:

• Microsatellite Instability (MSI)
• Immunohistochemistry (IHC)

Most private insurers cover this testing for patients who meet specific criteria. Surgeons who conduct Lynch-related biomarker testing are generally knowledgeable about established clinical and insurance coverage guidelines, and can advocate on your behalf if needed.

Patients with tumor test results that suggest Lynch syndrome may be referred for genetic counseling and/or testing for an inherited genetic mutation. This is typically covered by insurance but copays, coinsurance and deductibles may apply.

Health insurers may deny coverage for certain treatments if they are considered experimental, “off label” or differ from the standard clinical treatment pathway. If your health plan denies any treatments or cancer-related services your health care team can help you appeal the decision by demonstrating medical necessity. Visit our Health Insurance Appeals section for additional guidance and resources.

Fertility Preservation

Fertility preservation is not typically covered by insurance. However, several states have passed fertility preservation coverage laws. These laws specify that insurers must cover certain fertility services for individuals who may experience “iatrogenic infertility,” meaning infertility caused directly or indirectly by surgery, chemotherapy, radiation or other medical treatment. Note that some states only cover fertility preservation (sperm or egg retrieval) while others cover additional services such as In Vitro Fertilization (IVF). Deductibles, coinsurance and copays typically apply.

Religious employers have the option to request an exclusion if coverage conflicts with their beliefs and practices. Even in states where coverage is not required, some self-insured companies offer insurance coverage for fertility preservation. It is important to check with your insurer to find out if you have coverage, and if so, for what procedures.

If you do not have insurance coverage for fertility services, you should ask about fertility preservation discounts. Many clinics will provide significant cost reductions for patients who need fertility preservation procedures. In addition, some hospitals and adolescent & young adult (AYA) programs have charitable funds available to help offset sperm banking and other preservation costs.

There are also grants and discounts available through established financial assistance programs.