Ask CancerCare

A. Many of the prominent provisions of The Patient Protection and Affordable Care Act will not take effect until January 1, 2014. However, significant changes will occur in 2010 and 2011. Here's a summary with highlights:

• People with pre-existing conditions who have been uninsured for 6 months or more will be able to purchase insurance coverage through a national "high-risk pool". Some people may also be eligible for subsidized premiums.

• Existing insurance plans will be barred from imposing lifetime limits on coverage. Annual limits on coverage will end in January 2014.
• Insurers will be prevented from canceling coverage retroactively (for example, if the policy holder gets sick).
• Insurers will not be allowed to exclude coverage of pre-existing medical conditions for children under age 19.
• Dependent children will be able to remain on their parents' health insurance until the age of 26.
• Medicare recipients who are in the Part D "doughnut hole" will receive a $250 rebate.
• Generics will be approved within 12 years of patent.
• More funding will be available to compare the effectiveness of medical treatments.
• A new division, the Federal Coordinated Health Care Office, will improve coordination of care for those who receive both Medicare and Medicaid.

• Medicare recipients who are in the Part D "doughnut hole" will receive a discount of 50% on brand-name drugs.
• Certain types of preventive care will be available to Medicare and Medicaid recipients at no cost.
• Non-profit hospitals will be required to publicize financial assistance programs and charge those eligible for financial assistance the same as what an insured patient would be billed.
• A new, voluntary long-term care insurance program will be created to help cover the cost of non-medical services and supports (such as custodial care) for those who are disabled and remain at home. The program will be financed through voluntary payroll deductions: all working adults will automatically be enrolled in payroll deductions unless they opt out.

• Insurers will not be able to refuse coverage to anyone with a pre-existing condition.
• State-run insurance "exchanges" will offer insurance policies to people who don't get their coverage through an employer or a government- subsidized program. Those who buy insurance through an exchange and have low-to-moderate incomes will be eligible for subsidies to pay for their premiums.
• More people will be eligible for Medicaid.

Other comprehensive sources of information include The Kaiser Family Foundation and The Medicare Rights Center. The federal government will launch a consumer-friendly website in July 2010 with more details on health care reform, as well as current and future coverage options.

A. When you become eligible for Medicare you receive Part A, which covers certain hospitalization costs. If you want coverage for outpatient services, you should choose Part B as well. Even with Medicare A and B there are still "gaps" in coverage: for example, there is a 20% co-insurance fee for Part B services, and neither A nor B offer drug coverage. Most people choose to supplement their coverage with a retiree plan if their former employer offers it, or a "Medigap" plan, which plugs most of the holes in coverage (except medications). The rest, roughly 18%, choose a Medicare private health plan, called a Medicare Advantage Plan. These plans must offer at least the same benefits as original Medicare but have different rules, costs and coverage restrictions.

Medicare Advantage plans can be useful for those looking for all-in-one medical and drug coverage. However, Medicare Advantage HMOs restrict which doctors and hospitals you can use. An article in Kiplingers magazine sums up the differences well: "Medicare Advantage plans may charge lower premiums than you'd pay for Medicare plus a medigap policy and Part D prescription-drug coverage. But you could end up paying higher out-of-pocket costs throughout the year. Some Medicare Advantage plans charge higher co-payments for big-ticket items such as hospitalization, or for critical services such as chemotherapy. Or they might not pay for the first 20 days in a skilled-nursing facility (which traditional Medicare covers). In addition, a plan may provide limited coverage if you travel out of state." Please review this list of questions to ask before you join a Medicare Advantage plan.

Please note: A recent study of cancer patients by an affiliate of the University of Pittsburgh Cancer Institute suggests that members of Medicare Advantage HMO plans are opting out of clinical trials because these policies generally require that the patient pay 20% of the costs associated with a trial. In contrast, Medigap plans generally cover those costs.

You can learn more about Medicare coverage options and find plans in your area by visiting the Medicare website. The Medicare Rights Center is also an excellent resource for Medicare questions.

A. The American Recovery and Reinvestment Act (otherwise known as the "stimulus package"), signed into law on February 17, 2009, includes a subsidy to help people pay their COBRA premiums. COBRA is a law that lets you keep your employer-sponsored insurance for 18 months (sometimes longer) after you've left your job or become ineligible for benefits. Here is a quick rundown of the most important aspects of the subsidy:

• The government will pay 65% of COBRA premiums for people who lost their employer-sponsored insurance between Sept. 1, 2008 and Dec. 31, 2009.
• The subsidy lasts for nine months.
• People who lost their jobs after Sept. 1, 2008 but didn't sign up for COBRA at the time will be able to do so now.
• Your former employer should send you a notice about your eligibility by mid-April. You'll then have 60 days after that to act.

For more detailed information about COBRA and the stimulus package, please visit Families USA.

A. If you are insured and struggling with outstanding medical bills, consider the following options:

• Read your insurance policy and understand the terms of your contract. If you have questions, ask your insurance company, insurance broker, or the human resources staff at your employer to explain it to you. Your insurer may have denied a claim even though you are entitled to coverage. The Kaiser Family Foundation has an excellent guide on how to dispute claims with your insurer.
• Double check all bills and EOBs (explanation of benefits). You'd be surprised how often billing mistakes are made. Look for incorrect dates of service (you shouldn't be billed for the room on the day you were discharged) and duplicate fees for tests and procedures.
• Ask the hospital or doctor to consider the insurance payment as "payment in full." Many people don't think to do this, and it is often more successful than expected. Some hospitals have funds to offset medical services that aren't fully covered by insurance.
• Negotiate the outstanding balance by asking for a discount. According to a Wall Street Journal survey, 70% of adults who talked with a hospital say they were successful in negotiating a lower price for their medical bills; 61% were successful with their doctor. You will likely get a greater discount (sometimes as high as 50%) if you pay the outstanding balance in a lump sum. You can also set up a payment plan.
• The Volunteer Lawyers Project of the Boston Bar Association offers good advice on medical debt. Although some of the information is specific to Massachusetts, sections like "deciphering a medical bill" and "negotiating tips" are useful wherever you live. Healthinsuranceinfo.net also has a concise guide on managing medical debt .
• Explore the resources listed in the previous Q&A (below) for more information about co-payment and other medical cost assistance.

Remember to reach out for help—medical debt understandably causes emotional stress and it's important to get as much support as you can. Speaking with a counselor can help you manage some of your stress and come up with a plan so that you feel more in control.

A. Direct financial assistance for co-pays is limited, but it does exist. The following non-profit organizations provide help for expenses such as drug co-payments, deductibles, and other medical costs. Each program has its own eligibility requirements, so please contact them to learn more.

• CancerCare Co-Payment Assistance Foundation
• Patient Access Network Foundation
• Healthwell Foundation
• Patient Advocate Foundation's Co-Pay Relief Program
• Patient Services Incorporated
• National Organization for Rare Disorders
• Leukemia and Lymphoma Society

In addition, the Partnership for Prescription Assistance has a comprehensive database of pharmaceutical companies that offer their medications at little or no cost to those who qualify.

You can also find more information and resources through Cancer.Net's patient guide, Managing the Cost of Cancer, and CancerCare's "Financial Help for People with Cancer" [español] .

A. I understand your concern about the cost, but if you think you have cancer, you can't afford not to visit the doctor. Cancer responds to treatment better when it's caught early, and if it turns out that you don't have it, you will have peace of mind.

There are 3 main ways to get health insurance:

1. An employer, union, professional association or other job-related source: If you have a job and your employer offers health insurance, ask if you're eligible to receive it or buy into it. If you had insurance but lost your job within the last 60 days, ask if you're eligible for COBRA. COBRA is a law that lets you keep your insurance for 18 months, sometimes longer. You pay the full cost. If you are self-employed, see if there is a professional association in your state that offers group coverage at discounted rates. If you are a small business owner, check with your local Chamber of Commerce.
2. Buy it on your own: Compare plans and prices by speaking with an insurance broker or visiting an online broker like www.ehealthinsurance.com. Please note that your rights as a consumer are different in every state: in most states, insurance companies can refuse to sell you insurance based on your age, gender, or medical history (but not in New York, New Jersey, Massachusetts, Maine, Vermont, and, with limitations, Washington); in all states they can exclude pre-existing conditions from coverage for a period of time (however, there might still be circumstances in which you would be eligible for coverage). You may also be protected by a law such as HIPAA. Before you buy anything, please visit The Kaiser Family Foundation for information on your rights.
3. State and federal health care programs: You may be eligible for health care based on your age, income, or pre-existing disability. To see what programs are available in your state, visit The Foundation for Health Coverage Education.

If you are unable to buy insurance and are ineligible for public programs, you have 2 main options:

1. High risk pools or insurers of last resort: Roughly 30 states allow patients who have been denied coverage due to pre-existing conditions to buy a policy through a "high risk pool." The cost may be high and there may be a waiting list, but it's cheaper than being uninsured and paying out of pocket. The National Association of State Comprehensive Insurance Plans lists pools by state.
2. Hospitals and clinics: Ask about charity care and sliding scale programs (fees based on your income) at hospitals and clinics. Some hospitals are required to see patients who are uninsured. Contact your local department of public health, social services, or business office of your hospital of choice for more information.

Finally, if you are concerned about either breast or cervical cancer, the National Breast and Cervical Cancer Early Detection Program provides low-income, uninsured women access to screening and diagnostic services to detect breast and cervical cancers. Women who are subsequently diagnosed with cancer may be immediately eligible for limited Medicaid.