Will My Insurance Company Cover the Cost of Proton Treatment?
California Protons works with all insurance plans and is contracted with many private insurances, as well as Medicare. Our Insurance Team works closely with each patient to help them navigate through the process. Because each patient is unique and insurance plans differ, there is not a one-size-fits-all approach to coverage. If an insurance company initially denies services, the Insurance Team assists with the appeal process. Fortunately, we often are successful with the appeal process. See below for other insurance-related FAQ’s.
HOW DO I FIND OUT IF MY HEALTH INSURANCE COMPANY WILL COVER MY PROTON TREATMENT?
The first step is to schedule a consultation with a California Protons Cancer Therapy Center patient advocate to review your treatment plan. Following your consultation, our Insurance Team and physicians can contact your insurance provider on your behalf to determine your coverage.
Call 858.299.5984 to schedule your consultation. Consultations are typically covered by insurance.
HOW DOES CALIFORNIA PROTONS CANCER THERAPY CENTER HELP ME OBTAIN APPROVAL FOR PROTON TREATMENT?
While coverage is not guaranteed for every carrier, our representatives and physicians work directly with your insurance plan every step of the way, including:
- Responding to their questions
- Writing letters of medical necessity and submitting supporting documentation on your behalf
- Participating in peer-to-peer discussions regarding your treatment
- Providing comparative treatment plans
When needed, submitting letters of appeal on your behalf.
DOES MEDICARE COVER PROTON THERAPY?
Medicare typically pays for 80 percent of covered services. In many cases, secondary Medicare insurance will cover the remaining 20 percent.
WHICH PRIVATE INSURANCE COMPANIES COVER PROTON THERAPY AND FOR WHAT TUMOR SITES?
Private insurance companies generally cover proton therapy on a case-by-case basis, depending on the type of tumor being treated, previous treatments, medical history and other factors. California Protons Cancer Therapy Center works with a variety of insurance providers, and our insurance specialists will work with your provider to determine your coverage.
EVEN IF MY INSURANCE COVERS PROTON THERAPY, HOW DO I KNOW WHAT MY OUT-OF-POCKET COSTS ARE?
The California Protons Cancer Therapy Center Insurance Team will contact your insurance company to confirm your eligibility, benefits, deductible amounts and co-payments/co-insurance requirements. We will then determine how much your out-of-pocket costs will be.
WHAT IF MY INSURANCE CARRIER IS OUT-OF-STATE?
California Protons Cancer Therapy Center is contracted with many insurance companies outside of California. If we are not contracted with a provider, we will negotiate a letter of agreement for all approved services.
CAN I GET COVERAGE FOR PROTON THERAPY IF I CHANGE INSURANCE COMPANIES?
If your current insurance provider will not cover treatment, you may be able to switch to another provider that does. However, private insurance companies generally provide coverage on a case-by-case basis. We do not advise changing insurance providers unless you have determined that your new provider will cover your treatment.
IS MY PROTON THERAPY CONSULTATION COVERED BY INSURANCE?
In most cases, insurance companies cover the cost of the consultation. If necessary, we will assist in obtaining authorization to cover the consultation.
WHAT HAPPENS IF MY INSURANCE COMPANY DENIES PROTON THERAPY COVERAGE?
In most cases, we will file an appeal with the insurance company on your behalf. If coverage continues to be denied, California Protons Cancer Therapy Center offers a cash payment plan at a significant discount.
HOW DO I APPEAL TO MY STATE OR STATE’S DEPARTMENT OF MANAGED HEALTH CARE?
If your insurance company denies your appeals, they should send you instructions. In most cases, you are responsible for taking this step, as this request must come from the patient.
ARE THERE ACTIONS I CAN TAKE IF MY INSURANCE CARRIER DENIES THE APPEAL?
If the appeal is denied, you can take several steps:
- Seek help from one of the many nonprofit and for-profit entities that offer advice. Many states have health insurance consumer advocates.
- Talk to others who have had the same diagnosis and have been treated with proton therapy.
- Conduct Internet searches for people who have had proton therapy for your condition.
- Share your story on social media outlets to publicize your efforts and locate others who may be able to help.
If coverage continues to be denied, California Protons Cancer Therapy Center offers a cash payment plan at a significant discount.
For more information about proton therapy or to talk to one of our nurses, call 858.299.5984.