Be the Boss Over Cancer

Insurance Legislation

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Will I be able to stay on my employer’s insurance policy? 

If you are taking leave, look into how long you will be allowed to stay on your employer’s health insurance policy by contacting human resources. If you are terminated because leave time runs out, or you have chosen to reduce your hours so that you are no longer eligible for benefits, consider the following:

COBRA is a federal law that applies to employers with 20 or more employees that allows you to continue the same employment-based health insurance coverage that you had while they were employed, usually for 18 months. COBRA is available to an employee or family member after an employee has terminated their employment or has reduced their work hours to a point that they are no longer eligible to receive coverage from their employer. This termination or reduction in hours is referred to as a “qualifying event.” The good news about COBRA is that you do not have to change health care providers and will maintain the same coverage you previously had. The bad news is that the coverage is no longer subsidized by the employer and you have to pay the full premium, which can be expensive. There is a program in some states called the Health Insurance Premium Payment Program (HIPP), which can help pay for an individual’s health insurance premium. In addition, some states have mini-COBRA laws that require employers with between 2 and 19 employees to offer continued coverage.

What do I do if the time period to stay on my employer’s insurance through COBRA runs out? 

First, make sure you know exactly when your COBRA coverage ends, so you can plan for it. Getting on a Health Insurance Portability and Accountability Act (HIPAA) individual plan might be an option for you. 

HIPAA, as a law, does many things, including: provides a federal right to an individual health insurance plan (called a guarantee issue plan). You must, however, meet three requirements to be eligible for a HIPAA plan: First, you must exhaust your COBRA coverage, meaning that you use all 18 or 36 months of COBRA coverage, or state COBRA coverage. Second, you cannot have a break in coverage longer than 63 days (which is why it is important to know when your COBRA coverage runs out and plan ahead when possible). Lastly, you must be ineligible for Medicare, Medicaid, or any other form of group coverage.

If you’re not able to get insurance through COBRA, and you’re not eligible for a HIPAA plan either because you did not exhaust the available COBRA coverage or if you had a break in coverage of more than 63 days, then you may be eligible for a state high risk insurance pool or a major risk plan. Some states that provide this form of high-risk medical insurance for people who are unable to obtain health insurance coverage in the individual insurance market due to a pre-existing condition. The type and availability of coverage that you receive varies depending on your state. 

As of January 1, 2014, the Patient Protection and Affordable Care Act (ACA), provides the opportunity for anyone to shop for insurance in their state's Health Insurance Marketplace.  Health insurance companies can no longer deny selling you a policy, or charge you more, because of your pre-existing condition.  Unlike with COBRA coverage, this will be a completely new policy, so make sure that you shop carefully and pick a policy that covers your doctors, hospitals, and prescription drugs you need. Shopping for a new plan can be done immediately after your qualifying event, after your COBRA runs out, or at any other point in that time frame.  For more information about the Marketplaces, visit healthcare.gov.

Don’t take “no” for an answer if your insurance company denies coverage

Insurance coverage denials are unfortunately fairly common. Some denials stem from administrative errors, incorrect billing codes and errors on forms. It is important to check to see if any of those apply, and even if there is a more substantive reason for the denial, to then proceed through the internal appeals process. Internal appeals can take time and energy, but could be worth the hassle. Ask for patient navigation assistance or someone close to you for help. If you still aren’t getting the answer you want, you can move to the external medical review process, which is supposed to provide an independent review of your request. All states have an external appeals process. It can be worth going through the external appeal, since this decision is generally binding on the insurance company. For more information contact your state’s insurance agency.  To find the contact information for your state's agency, visit: http://triagecancer.org/resources/stateresources/.  

You may also want to use this Appeals Tracking Form created by Triage Cancer to keep track of where you are in the process.  If you feel that you need assistance from an attorney, you may consider contacting the National Cancer Legal Services Network (NCLSN) or LawHelp.org

Please note that this information is designed to provide general information on the topics presented. It is provided with the understanding that the expert is not engaged in rendering any legal or professional services in the information provided. The information provided should not be used as a substitute for professional services.