Prostate Cancer and Health Insurance

Prostate cancer is presently the leading cancer affecting men in the United States aside from skin cancer, with an estimated 241,740 new cases diagnosed in 2012. This disease also led to the second highest number of cancer deaths in the nation among men this year, ending a projected 28,170 lives. The beginning stages of prostate cancer are difficult to detect, as symptoms are scarce. As the cancer develops, noticeable and painful symptoms arise in the urinary tract, and the advanced disease generally spreads to the bones, causing pain in hips, ribs, and other regions. Prostate cancer is more likely to occur in a person with genetic predisposition to the disease, as well as poor diet, high alcohol intake, and other factors.

Treatment and prevention of prostate cancer are heavily concentrated in the development of chemoprevention drugs, which lower specific male hormones. Preventive screening for prostate cancer is recommended from age 50 for men who have an average risk level, and 45 for those with a high risk level, such as those with a family history of prostate cancer or African American men. As with other cancers, treatment varies based on the patient, and may involve surgery, radiation, or radioactive seed implants. Hormonal therapy or chemotherapy may also be implemented in certain cases. The positive outlook for those diagnosed with prostate cancer is that the survival rate has increased over the past 25 years, and those who do not smoke and keep a healthy weight have a better likelihood of outliving their disease.

While coverage was previously hard to come by if you were diagnosed with prostate cancer, health reform makes it possible to buy insurance with any company. Your insurer is also unable to cancel your benefits based on your health, if you are already enrolled in a plan. This law is a great help for men with prostate cancer as well as all Americans with health problems, allowing people to get coverage and stay insured. Below is a look at how health insurance works now, what it was like before the Affordable Care Act, and your choices when it comes to coverage.


Prostate Cancer and Insurance: Past and Present



Health Reform & Prostate Cancer

Everyone’s favorite landmark health care law made a positive impact on anyone with prostate cancer, as access to health insurance is broadened. The Affordable Care Act is especially wonderful for anyone with a condition like prostate cancer, who have experienced immediate declines or unsightly rate hikes, as these are longer permissible. From the start in 2010, we could see helpful changes through the creation of the PCIP program and the states who had expanded their Medicaid programs before 2014. Now that the law is fully implemented, there is a lack of discrimination among insurers for conditions. People with prostate cancer will be able to walk into any health insurance company they please and be accepted for coverage without an issue, an exclusion period, or a drastic rate increase.

Additionally, those who are unable to afford health insurance may receive subsidies to lower monthly premiums and medical costs on the state health insurance exchanges. The very low-income will still be able to gain coverage through Medicaid, though in certain states, the program has expanded to include a new group: low-income adults without children or disabilities. While Medicaid expansion is optional, the states who chose to proceed with these changes under health reform will greatly help the poor population in their state, especially those suffering from cancer. The law has also made adjustments to Medicare in order to help people with serious health conditions get the attention and care they require.



Before the law took effect, health insurance companies were quite regrettably biased against applicants with cancer in their past or present. Typically, a person would be declined if they had any instance of cancer in the past two years, though other insurers varied. The most common cancers were usually at the top of the declinable conditions list, or truly, any cancer at all besides those affecting the skin. An individual with prostate cancer would either be declined on the spot, or have their medical records reviewed before a decision was reached. Many insurers would ask for your oncologist to send your history, current diagnosis, and past treatment to verify the severity of the disease. Based on these factors, an insurer had the right to decide if you were insurable or not.

If the cancer spread, you would be declined immediately, as this poses a much higher risk for expensive medical bills. Metastatic cancer was a declinable condition for virtually every health insurance company, which means if you had reached this advanced stage, you would need to seek another source of coverage, like the Pre-existing Condition Insurance Plan. The underwriting process used by each insurer was different, though for certain cancers the outcome was fairly predictable. Even the most lenient of underwriting guidelines put its foot down in the cancer category. In this case, it would be recommended that you maintain a consistent source of coverage throughout your younger, non-symptomatic years, and receive the preventative care recommended.

You could not be declined coverage based on genetics that placed you at a greater probability of acquiring prostate cancer before health reform, which remains the same today. If you smoked, were obese, or had other health problems, your rates may have increased, but your inherited factors will not likely result in an increase if you are otherwise in good health. Also, if it had been several years since your diagnosis, and your disease remained dormant, you might have been able to buy a health plan, though your premiums might have gone up with the elevated risk of the cancer recurring.

None of these outcomes can occur under the Affordable Care Act. If you have any questions regarding the new laws or your health insurance options, consult a licensed agent at 888 803 5917.


Health Insurance Plans

There are several other choices a person with prostate cancer has for insurance coverage besides individual health plans, though these are more often than not the most suitable for a majority of Americans, namely the self-employed. Most likely, if you applied for a plan on the individual market, you did not have the choice of coverage through your job. The individual market may be your best bet as they accept all applicants with conditions and features plans designed for comprehensive health care, which may include cancer-specific needs. If group and individual health plans are out of your price range, contact your state and find out if you are eligible for Medicaid or a subsidized plan on the exchange. Now that the health care reform law is in place, there are a few more ways to get health insurance, especially for those with a condition.


Health Insurance Exchanges

The health insurance marketplace is a byproduct of the Affordable Care Act, created to insure people who do not have coverage at work or through Medicaid. Applicants must be U.S. citizens or legal residents in order to qualify, and not have a comprehensive group plan offered to them at work. These plans may cover care for specific illnesses, as well as the usual range of primary, preventive, and major medical care. With prices similar to individual coverage, exchanges differ in that you can apply for tax credits to lower your premiums and out-of-pocket expenses.

As prescriptions are en essential health benefit, exchange plans cover a number of medications, though you may want to get a discount card for non-formulary drugs, such as chemotherapy prescriptions. Though all plans will cover people who need the care, they do not cover everything. Be conscious of your benefits and make necessary preparations if you know you need a certain medication or service, to seek some sort of discounted rate, either through the pharmacy or a public health provider. Plans are sold by private insurers, so you are connected to their network once you join, although the exchange itself is run by the state or federal government.


Employer-Sponsored Coverage

If you have health insurance available through your job, you may consider joining the group, as some plans have comprehensive benefits. For someone with medical needs, it is essential to get any coverage you are able to, but make sure the plan covers enough services before you enroll. Employer-sponsored plans cannot decline anyone for their health, like all insurers, and they cannot increase premiums based on cancer or any other illness. Private insurers may not cover everything you need, which all depends on the plan. However, in the case of medical necessity, insurers are unable to deny a claim for cancer treatment, a surgery, tumor biopsy, etc. As long as you rightfully prove your health is being threatened, the insurer should comply. If not, report them to the insurance department.

These plans also typically come with a limited formulary, giving access to only a select number of prescription drugs. Find yourself a discount card for the more costly medications you require if they are not covered. Also, be sure to check your provider list to make sure you are using a doctor or facility that your plan will cover. This is also important for individual plans, or any other sort of health plan.



Low-income Americans in every state have access to the Medicaid program, if their income meets a certain level. Adults with prostate cancer may fall into one of several categories covered by the program, including low-income adults with children, low-income adults without children (in select states), adults with disabilities, or dual eligible Medicare beneficiaries. These groups determine which Medicaid plan you will be issued and your income is evaluated based therein. Though these income limits vary from one state to another, if accepted, they may cover any necessary treatment for prostate cancer in any stage. Costly medications are unlikely to be covered, though you can attempt to get a discounted rate through a retail program or an insurer’s discount card.

Medicaid members have access to a wide number of medical services through their state’s public health system. Most care is free of charge depending on your state, as the state and federal government pay for the cost of services. Check with your state‘s Department of Health for enrollment and eligibility information regarding their program rules and current status.



As many recipients of prostate cancer are older, Medicare is the obvious option for Americans who are age 65 and older. Whether you purchase a Medicare Advantage plan through a private insurer or receive government assistance, the elderly can join the complicated web of health care and coverage that is Medicare. Individual and family health plans unfortunately stop selling plans to people over age 64, as Medicare rules the system for older citizens. Though each plan varies immensely, and you must be very careful when choosing providers, care for prostate cancer should be made available and covered by Medicare.

Part D covers medications, though also limited, and not fond of expensive prescriptions. Call us for guidance on Medicare plans if you have any questions. We can help you understand the program better, or impart some wisdom about your coverage. You may also want a Medicare Supplement policy to cover health problems your plan does not. It is necessary to do the research before receiving care, and even before choosing a plan. Every detail can affect your ability to get the care you need.




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1. American Cancer Society. “Cancer Facts & Figures 2012″.