Proton therapy is covered by many private insurance plans, Medicare and many state Medicaid programs. The cost of proton therapy varies according to the diagnosis and the extent of treatment needed. Because coverage evaluation for proton therapy depends on each patient's specific tumor type and insurance plan, the length of time it takes to determine coverage varies from case to case. Our financial counselor at the center will assist you in understanding your insurance coverage, coordinating insurance payments and finding alternative means of financing.

COMMON INSURANCE TERMS

W have provided explanations to a few terms you might come across as you start the insurance evaluation process with our financial counselor:

BENEFIT DESIGN - The process a MCO (Managed Care Organization) uses to determine which benefits or the level of benefits that will be offered to its members, the degree to which members will be expected to share the costs of such benefits, and how a member can access medical care through the health plan.

CARVE-OUT - Specialty health service that an MCO obtains for members by contracting with a company that specializes in that service.

CASE MANAGEMENT - A process of identifying plan members with special healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum healthcare outcome in an efficient and cost-effective manner.

CLAIM - An itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

COINSURANCE - A method of cost-sharing in a health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.

COBRA (CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT)  - A federal act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee, and termination of employment.

COPAYMENT - Specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered.

DEDUCTIBLE - A flat amount a group member must pay before the insurer will make any benefit payments.

FULLY FUNDED PLAN - A health plan under which an insurer or MCO bear's financial responsibility of guaranteeing claim payments and paying for all incurred covered benefits and administration costs.

HIPPA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT) - A federal act that protects people who change jobs, are self-employed, or who have pre-existing medical conditions. HIPAA standardizes an approach to the continuation of healthcare benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.

INDIVIDUAL STOP-LOSS COVERAGE - A type of stop-loss insurance that provides benefits for claims on an individual that exceed a stated amount in a given period. Also known as specific stop-loss coverage.

LIFETIME MAXIMUM BENEFIT AMOUNT - The maximum dollar amount set by an MCO that limits the total amount the plan must pay for all healthcare services provided to a subscriber in the sub-scriber's lifetime.

MANAGED CARE - The integration of both the financing and delivery of healthcare within a system that seeks to manage the accessibility, cost, and quality of that care.

MCO (MANAGED CARE ORGANIZATION) - Any entity that utilizes certain concepts or techniques to manage the accessibility, cost, and quality of healthcare. Also known as a managed care plan.

MEDICAID - A jointly funded federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

MEDICAL DIRECTOR - Manager in a healthcare organization responsible for provider relations, provider recruiting, quality and utilization management, and medical policy.

MSA (MEDICAL SAVINGS ACCOUNT) - A trust that employees of small businesses may establish to pay for out-of-pocket medical expenses.

MEDICARE - A federal government hospital expense and medical expense insurance plan primarily for elderly and disabled persons. Medicare Part A (basic hospital), Medicare Part B (physician services).

MEDICARE SUPPLEMENT - A private medical expense insurance plan that supplements Medicare coverage. Also known as a Medigap policy.

NETWORK - The group of physicians, hospitals, and other medical care providers that a specific managed care plan has contracted with to deliver medical services to its members.

OPEN ACCESS - A provision that specifies that plan members may self-refer to a specialist, either in-network or out-of-network, at full benefit or at a reduced benefit, without first obtaining a referral from a primary care provider.

OUT OF POCKET MAXIMUMS - Dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period.

PEER REVIEW - The analysis of a clinician's care by a group of that clinician's professional colleagues. The provider's care is generally compared to applicable standards of care, and the group's analysis is used as a learning tool for the members of the group.

POS (POINT OF SERVICE PRODUCT) - A healthcare option that allows members to choose at the time medical services are needed whether they will go to a provider within the plan's network or seek medical care outside the network.

PPO (PREFERRED PROVIDER ORGANIZATION) - A healthcare benefit arrangement designed to supply services at a discounted cost by providing incentives for members to use designated healthcare providers (who contract with the PPO at a discount), but which also provides coverage for services rendered by healthcare providers who are not part of the PPO network.

PRECERTIFICATION - Authorization to deliver healthcare service that is issued before any service is rendered.

PCP (PRIMARY CARE PHYSICIAN) - A physician or other medical professional who serves as a group member's first contact with a plan's healthcare system. Also known as a primary care physician, personal care physician, or personal care provider.

SELF-FUNDED PLAN - A health plan under which an employer or other group sponsor, rather than an MCO or insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as self-insured plan.

STOP-LOSS INSURANCE - A type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insurance to reimburse the insured organization for claims paid in excess of a specified yearly maximum.

TPA (THIRD PARTY ADMINISTRATOR) - A company that provides administrative services to MCOs or self-funded health plans.