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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, 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) plan might be an option for you. 

HIPAA, as a law, does many things, including: 1) provides a federal right to an individual health insurance plan (called a guarantee issue plan); 2) reduces the maximum pre-existing condition exclusion period to 12 months; and 3) gives you credit for the time that you had health insurance coverage in the past to eliminate or reduce a pre-existing condition exclusion period. 

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. 

In addition to state high risk insurance options, the Patient Protection and Affordable Care Act, otherwise known as healthcare reform, mandated that states create Pre-Existing Condition Insurance Plans. Some states opted not to create these plans. In those states, the federal government runs the plan. In order to be eligible for the federal program, you must: 1) be a U.S. citizen or in the US lawfully; 2) have a pre-existing illness or condition; and 3) have not had creditable coverage for six months.

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. Many states have had external medical review for a number of years. Under health care reform, all states should now 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.

The Cancer Legal Resource Center (CLRC), a 14 year old program of the Disability Rights Legal Center, offers free information and resources on cancer related legal issues to patients, caregivers, healthcare professionals and employers.  The CLRC provided this overview of the employment-related legal questions that often come up for patients, if you have specific questions about your legal rights in the workplace please contact the Cancer Legal Resource Center directly at 1-866-THE-CLRC or clrc@lls.edu for more information.

This material is designed to provide general information on the topics presented. It is provided with the understanding that Cancer and Careers and the Cancer Legal Resource Center (CLRC) are not engaged in rendering any legal or professional services by its publication or distribution. Although this material was reviewed by a professional, it should not be used as a substitute for professional services. Resources and referrals are provided solely for information and convenience.