Canopy Cancer Care is an Affiliated Provider to Southern Cross Health Society. This means that if you are a Southern Cross member, Canopy will apply for insurance pre-approval and also process claims on your behalf. If there is a shortfall, or a co-payment is needed you will be advised and asked to pay that directly to Canopy at the time of your visit.
If you have medical insurance with a provider other than Southern Cross, please read the following booklet for more information about medical insurance.
What is medical insurance?
Medical insurance is a type of insurance that covers medical costs in the event that you choose to be treated in a private medical clinic. Medical insurance plans or policies with the various providers can be tailored to your needs. When you take out the policy you will be named the primary policy holder but you may later nominate additional people who can manage your policy on your behalf.
There are many different medical insurance policies:
Each insurer has a variety of different policies, offering significantly different levels of cancer treatment cover. You will have discussed your needs and budget with either a broker or the insurance company directly to establish which policy is right for you.
The dollar amount of insurance cover will vary significantly from policy to policy:
This is to ensure that individual needs and budgets are catered to.
The drugs that are covered will vary from policy to policy:
• Pharmac funded drugs:
Pharmac is the government agency responsible for deciding which medicines and drugs are used in the public health system. Pharmac also negotiate purchase prices with the supplying drug companies on behalf of the Ministry of Health. All private insurers will cover the cost of Pharmac funded drugs for Pharmac approved conditions up to your policy limit. Insurers will also cover the cost of delivering the drug, called the Oncology Treatment Fees (OTF), up to your policy limit. Some insurers may require the doctor to apply for a Special Authority for certain Pharmac funded drugs.
• Medsafe approved drugs:
Medsafe is the business unit of the Ministry of Health that is responsible for reviewing and approving drugs for use in New Zealand. Some insurers will cover drugs that are Medsafe approved but are not funded by Pharmac. Those that do may only cover a low $ value limit (cap). Most insurers will cover the drug Oncology Treatment Fees (OTF) up to your policy limit.
• Non Medsafe approved drugs (Section 29 Drugs):
These drugs have yet to be approved by Medsafe for use in New Zealand, but may be in use widely in other countries, sometimes for many years. Very few insurers will cover these drugs, but most insurers will cover the Oncology Treatment Fees (OTF) up to your policy limit.
Canopy will provide both the patient and their insurer with a written cost estimate for the proposed cancer treatment.
Insurance cover and shortfall:
• It is the patient’s responsibility to find out from their insurer what parts of the Canopy cost estimate will be covered by their policy as well as:
- The insurance $ value limit (cap)
- The anniversary date of the policy
- Any excess that may apply
- Any exclusions or elements of the Canopy cost estimate that the patient
will need to fund themselves
The patient can choose how they pay their Canopy account:
• Pay Canopy invoices themselves and later claim from their insurer (not applicable for Southern Cross patients)
• Have Canopy submit the invoice to the insurer and the patient subsequently pays Canopy any shortfall
The patient should advise the Canopy Accounts team of their preferred option
The patient may change the payment option at any time
Patients who choose to have Canopy submit their claims need to track their policy balance to ensure that they have sufficient funds remaining within the policy limit to pay for their treatment:
• Each time the patient is treated at Canopy, the practice submits a claim to the patient’s insurer. The insurer advises the patient how much has been paid to Canopy so the patient can keep track of how much of the policy allowance has been spent. Canopy Accounts can assist the patient by providing a summary of invoices and payments by the insurer along with a cost estimate for the remainder of the planned treatment.
Insurers do not share the following patient information with Canopy:
• Status of spend against patient annual policy limit ($ cap)
• The insurance policy limit ($ cap)
• The insurance policy anniversary date
Patients therefore need to take responsibility for keeping up to date with this information.
Treatment in a Private clinic and through the District Health Board (Public Hospital) is referred to as shared care:
• In some circumstances a patient may receive some part of the treatment at the public hospital and another part of their treatment at Canopy. When a patient has shared care through the public and private hospitals, the patient is still responsible for tracking their insurance spend against their annual policy limit.
For any queries around the insurance claim process please contact Canopy Accounts on +64 9 623 5602 or firstname.lastname@example.org
What Canopy patients need to know about medical insurance