Insurance
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The National Coalition of Survivorship offers, What Cancer Survivors Need to Know About Health Insurance.
The Georgetown University Health Policy Institute has created consumer guides for getting and keeping insurance for all 50 states.
- People with pre-existing conditions who have been uninsured for 6 months or more are able to purchase insurance coverage through the Pre-Existing Condition Insurance Plan. Some people may also be eligible for subsidized premiums.
- Existing insurance plans are barred from imposing lifetime limits on coverage. Annual limits on coverage will end in January 2014.
- Insurers are prevented from canceling coverage retroactively (for example, if the policy holder gets sick).
- Insurers are allowed to exclude coverage of pre-existing medical conditions for children under age 19.
- Dependent children are able to remain on their parents' health insurance until the age of 26.
- Medicare recipients who are in the Part D “doughnut hole” receive a $250 rebate.
- All new insurance policies must cover certain preventive screenings, such as breast, cervical, and colorectal cancer screenings, as well as flu shots and immunizations, without charging a deductible, co-pay or co-insurance. *Please note that diagnostic screenings are not covered under this provision.
- Generics are approved within 12 years of patent.
- More funding is available to compare the effectiveness of medical treatments.
- A new division, the Federal Coordinated Health Care Office, improves coordination of care for those who receive both Medicare and Medicaid.
- Medicare recipients who are in the Part D “doughnut hole” receive a reduction in cost of 50% on brand-name drugs.
- Certain types of preventive care are available to Medicare and Medicaid recipients at no cost.
- 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.
- Most (but not all) people will be mandated to have coverage, and a penalty will apply if you don’t.
- All new plans must offer an essential benefits package, including coverage for hospitalization, doctor visits, laboratory services, and medications, with limits on your out-of pocket costs.
- 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 for co-payment and other medical cost assistance.
- Through 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.
- 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.
- 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.
- Pre-Existing Condition Insurance Plan. Those who have been uninsured for 6 months or more and have been denied coverage can receive insurance through the Pre-Existing Condition Insurance Program. Pre-existing conditions are covered upon enrollment, and premiums are capped at the average cost of private policies in your area. The federal government will operate the Pre-Existing Condition Insurance Program in those states who choose not to create their own program. In 2014, insurers will no longer be able to deny anyone coverage and this program will end.
- 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.
Q. When I am no longer covered under my parents' policy, will I be able to get my own health insurance with a past history of cancer?
For young adults, many of whom do not have full-time jobs, getting adequate health insurance coverage is a concern. While each state has different guidelines for coverage, young adults can generally be covered under a parent’s insurance until the age of 25, and most universities and graduate schools offer student health benefits.
If you do not have health insurance, seek out a medical social worker with knowledge of the health insurance plans in your state who can help you understand the specifics of these plans and how to apply. I recommend a few resources:
The cost of cancer treatment and follow up care can be overwhelming at times. Seek out financial assistance programs for which you still may be eligible. Thoroughly review the type and cost of health insurance offered by any prospective employer. And speak with a medical or oncology social worker who can offer practical assistance to help you find adequate health coverage – the first step in your survivorship planning.
Answered by
Julie Larson, LCSW
Q. My dad has terminal cancer and he is currently at home. He has no insurance, but Medicaid is pending. We're trying to get hospice or some support. What can I do?
It must be a very difficult time for your family and you are to be commended in seeking out resources and support services that are available to assist your family.
Hospice is paid for through the Medicare or Medicaid Hospice Benefit and by most private insurers. If a person does not have coverage through Medicare, Medicaid, or a private insurance company, hospice will work with the family to make sure needed services are provided. In order to receive hospice services, your father’s doctor will need to make a referral to a local hospice provider. You may also contact a local hospice to find out what steps you should take.
The National Hospice and Palliative Care Organization (NHPCO) offers information and resources about end-of-life and hospice through its Caring Connections website. The Caregiver Resource Directory also can provide you with extensive information. We’ve created a fact sheet, Caregiving at the End of Life, that provides guidance as you care for your father.
It’s important that you continue to follow-up with his Medicaid application, as benefits will be retroactive to the date when he applied and can be used to pay any medical bills that may be incurred during the application period. CancerCare’s fact sheets, Getting to Know Your Entitlements and Sources of Financial Assistance, may also be helpful in finding resources.
If you continue to have difficulties finding hospice services for your father, please call us at 1-800-813-4673 (HOPE) to speak with an oncology social worker.
Answered by
Sandra Tripodi, MSW, LCSW, Regional Director, Connecticut Office
Q. I've heard so much about health care reform (Affordable Care Act), but I'm not sure exactly how I will be affected?
Many of the prominent provisions of The Patient Protection and Affordable Care Act will not take effect until January 1, 2014. However, significant changes occurred in 2010 and 2011. Here’s a summary with highlights:
June 2010:
September 2010:
During 2011:
Looking forward to 2014:
Other comprehensive sources of information include The Kaiser Family Foundation and The Medicare Rights Center. Healthcare.gov is the federal government’s consumer-friendly website providing more details on health care reform, as well as current and future coverage options.
Answered by
Renata Marinaro, LMSW
Q. How do I figure out which Medicare plan is right for me? I don't know if I should get a Medicare Advantage plan or a Medigap plan, or if I should just keep my original Medicare and do neither.
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 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.
Answered by
Renata Marinaro, LMSW
Q. I have insurance, but I still have bills that are stressing me out. I thought I'd be covered, but I don't know how I'm going to pay the part I'm being told I owe.
If you are insured and struggling with outstanding medical bills, consider the following options:
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.
Answered by
Renata Marinaro, LMSW
Q. I think I may have cancer but I don't have any insurance and I'm not sure I can afford it. What can I do?
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:
If you are unable to buy insurance and are ineligible for public programs, you have 2 main options:
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.
Answered by
Renata Marinaro, LMSW
Q. I receive Social Security Disability and Long-Term Disability. My doctor filled out my yearly forms to send to my insurance and said I was good to go back to work without discussing how I’m feeling. Now my insurance is sending me paperwork to go back to work and I don’t feel I am ready.
You should comply with the documentation requested by your insurance company, and should review any appeals policy available. However, you should also contact your doctor to discuss your medical condition and feelings about returning to work.
Please note that your eligibility for Social Security disability benefits is not affected by any decision made by any private insurance you may have. However, Social Security is required by law to review the medical condition of all people receiving disability benefits from time to time to make sure they continue to be disabled. Generally, if your health has not improved, or if your disability still keeps you from working, you will continue to receive your benefits. To better understand this process, you should read the publications, How We Decide If You Are Still Disabled and What You Need To Know: Reviewing Your Disability.
Answered by
Jacqueline Zahora, LCSW-R
Q. I am currently on my former employer's group insurance policy, and was able to maintain the benefits through COBRA. The policy is about to end and I have been trying to "find" another insurance carrier. I have been denied by a few agencies. Is there any advice you can provide?
Because you were covered by a group insurance policy and have exhausted your COBRA coverage, you are protected by the Health Insurance Portability and Accountability Act, known as HIPAA. This law mandates that people in your situation cannot be denied insurance coverage due to pre-existing conditions. However, there are some stipulations: 1) you must present a certificate of creditable coverage to the insurer, which shows that you are HIPAA eligible; 2) you cannot be eligible for government-subsidized insurance such as Medicare or Medicaid; 3) you must apply for a HIPAA plan within 63 days of losing your coverage.
The Cancer Legal Resource Center of the Disability Rights Legal Center has compiled a list of private insurance companies that offer HIPAA policies:
In many states, HIPAA-eligible individuals can buy insurance through high-risk pools, which are state-run programs that offer individual health insurance policies to residents who do not have access to group coverage and who have been denied individual coverage. The National Association of State Comprehensive Health Insurance Plans provides links to state high-risk pools.
HIPAA policies can be quite expensive. You may want to check to see if you’re eligible for Medicaid or another government-subsidized plan first. The Pre-Existing Condition Insurance Plan, a program instituted through the Affordable Care Act, also offers guaranteed access to coverage for people with pre-existing conditions, and rates are generally lower than those offered through high risk pools or HIPAA policies. However, you have to have been uninsured for at least 6 months in order to apply. To review what public and private insurance options are available in your state, visit the Foundation for Health Coverage Education’s website.
Answered by
Renata Marinaro, LMSW
For Cervical Cancer
- Medicaid is a jointly funded, federal-state health insurance program for people who need financial assistance for medical expenses. A current law exists that allows state Medicaid programs to provide treatment to women diagnosed with cervical cancer.
- Contact local hospitals to see what types of free care or charity care programs they offer. Speak with a financial counselor or social worker to explain your situation. Federal law requires that non-profit hospitals provide some amount of charity care in exchange for tax-exempt status.
- The Patient Advocate Foundation (PAF) provides education, legal counseling, and referrals to cancer patients and survivors concerning managed care, insurance, financial issues, job discrimination, and debt management.
- Contact local community or religious organizations that may be able to provide guidance and resources.
Q. What resources are available for women with cervical cancer who have no medical insurance? I was going to a specialist and my cancer was advancing. I have had no treatment since due to lack of insurance.
The many challenges of being diagnosed and not having insurance are stressful and emotionally difficult. Feelings such as anger and anxiety are very common, but these should not keep you from getting treatment. Give yourself credit for seeking help, and for learning about and using available resources.
Being organized can help ease some of your anxiety. Keep a notebook with a list of organizations you contact and write down the name of the person with whom you speak, and what information they provide to you.
Answered by
Julie Larson, LCSW
Additional Resources
Organizations
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Cancer and Careers
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Cancer Legal Resource Center
866‑843‑2572, cancerlegalresourcecenter.org
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Foundation for Health Coverage Education
800‑234‑1317, coverageforall.org
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Henry J. Kaiser Family Foundation
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Patient Advocate Foundation
800‑532‑5274, patientadvocate.org
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U.S. Department of Health and Human Services' HealthCare.gov