Whatever your insurance issue — no coverage, excessive out-of-pocket expenses, costly premiums or worries about future insurance coverage — here’s help, challenge by challenge.
Problem: No Insurance
If you are not offered insurance from your employer and you don't have your own private health insurance policy, you may be eligible to purchase health insurance through the Health Insurance Marketplaces or for a public program.
The Patient Protection and Affordable Care Act (ACA) created a new way for individuals to shop for, and purchase, health insurance. People cannot be denied, or charged more, for health insurance because they have a pre-existing condition like cancer. For more information about the Health Insurance Marketplace in your state, visit healthcare.gov.
In general, if you are age 65 and above and eligible for Social Security benefits or disabled at any age and have been collecting Social Security disability benefits for two years, you are eligible for Medicare health insurance. To check out details, see www.medicare.gov.
Medicaid is another possible option. This government program provides health insurance for low-income persons and their family members. Be aware that each state has its own Medicaid program; the rules vary from state to state. To find out about Medicaid in your state, visit the Georgetown University Health Policy Institute site, www.healthinsuranceinfo.net or healthcare.gov.
Some states also have their own public health insurance programs. New York, for instance, has the Family Health Plus. For details, read the state-by-state guides at www.healthinsuranceinfo.net.
Some states have high-risk pools, which may allow you to buy coverage if you have a pre-existing condition. However, many of these high-risk pools will be phased out over the next few years due to the fact that private health insurances can no longer deny selling policies to people with pre-existing conditions. For state-by-state details, visit www.statecoverage.org/node/5237, a website maintained by The Robert Wood Johnson Foundation.
Problem: Excessive Uncovered Expenses
Co-payments and uncovered expenses can add up quickly. If you have uncovered medical expenses that are beyond your ability to keep up with, here's what you can do:
- Acknowledge the problem. Talk to your doctor’s office (probably the office manager) or the hospital (ask for the best person to talk to).
- Consider asking if any funds are available, set aside for uninsured patients. Some philanthropists may have established such a fund.
- Create a payment plan. Another option is to work with your health care providers to set up a reasonable payment plan. Your good faith effort will go far. The goal is to keep your credit as untarnished as possible. Even if you pay what seems a nominal amount every month, keep sending something — for your own peace of mind as well as your credit rating. If you don’t pay anything, the fear of repercussions on your credit can paralyze you.
- Get outside help. You can also check out organizations that help insured patients who can't afford out-of-pocket costs, such as the Patient Access Network at www.panfoundation.org/.
- *Appeal insurance decisions. You can always appeal a decision that doesn’t seem financially fair to you. For example, if your insurance plan doesn’t cover something you feel should be covered, or doesn’t cover it to the extent you think it should be reimbursed. It’s your right to appeal, but many people overlook that or think it’s not worth it. Before appealing, however, check your policy. If it clearly says, for instance, that home care visits are covered for only three months, and you have used up that amount of visits, it’s probably futile to appeal. To appeal properly, contact your insurance representative, either at your company or the insurance company, to learn the procedure.
- Make a formal appeal. You can get substantial help doing this. The Patient Advocate Foundation, for instance, outlines the steps and includes sample letters in its booklet, Your Guide to the Appeals Process, which can be downloaded from its website (www.patientadvocate.org) or requested by mail by writing the headquarters, at 753 Thimble Shoals Blvd., Suite B, Newport News, VA 23606.
- Before writing the appeal letter, the guide suggests, be sure you understand your diagnosis and your coverage; get a copy of the denial letter and understand the basis on which the treatment or other care has been denied. According to provisions in the Federal Employee Retirement and Income Security Act (ERISA), a specific reason for the denial should be stated in the letter. If you don’t understand specifics in the letter, call the plan and ask for a contact person; have the representative explain exactly why the care has been denied.
- Re-appeal and External Appeals. If your appeal has been denied, you can re-appeal the decision. The ACA now requires each state to have an external appeals process, where you can appeal to a panel of outside experts; these panels overturn original denials in about half the cases .Be sure to check the National Association of Insurance Commissioners website: (www.naic.org) which provides links to specific state departments of insurance and other departments that regulate managed care.
- Ask about changing treatment schedules. To reduce your out-of-pocket expenses, you might also ask your doctor if you can spread out the routine tests you need, just slightly, without compromising your care. For instance, you might ask your doctor if you can take a blood test monthly instead of biweekly. You might also ask if he can prescribe generic drugs rather than brand names; again, only if it would not compromise the quality of your care.
- Ask about clinic options. If you are receiving care at a teaching hospital, or if your physician practices at one, you might ask if you can receive care through a clinic setting at the teaching hospital. Your own doctor may sometimes deliver care there, or he may refer you to a colleague who does. Getting treatment in that setting may take a bit longer, but the quality of care is excellent and the fees may be less.
Problem: Costly Premiums
Typically, if you are in a group plan provided by your employer, the employer determines which plan or package to make available to workers. And, you’re typically “locked in” for a set time period. But when and if a chance comes up to renew or change plans, and you have options, look carefully so you make the most informed choices you can.
You might get a choice, for instance, of an HMO or a preferred provider organization (PPO). The HMO is typically less expensive, but generally offers you few or no options to go “out of network” and use doctors that don’t belong to the HMO.
If you switch to an HMO, you may pay less for your premium but be forced to switch doctors.
In reviewing a new plan, watch out for high deductibles — they can be several thousand dollars. Be sure the deductible amount is a total you are comfortable coming up with.
Evaluate the prescription coverage in any new plan. Some cancer drugs are very expensive, and you should carefully consider whether giving up prescription coverage is worth the cost savings in the premium.
The same principles apply when shopping for individual insurance. If you shop in your state’s Health Insurance Marketplace there may also be some financial assistance available to you to help pay for your premiums. Eligibility for financial assistance is based on income level and family size. For more information, visit healthcare.gov or explore The Kaiser Family Foundation’s Subsidy Calculator.
Problem: Keeping Insurance Coverage
As of January 1, 2014, this is less of a problem for individuals coping with a cancer diagnosis. That is because health insurance companies can no longer deny you a policy based on your pre-existing condition.
If you leave your job and lose your employer’s health benefits, and you want to keep the exact same health insurance plan, you may be able to do so for a period of time under COBRA (Consolidated Omnibus Budget Reconciliation Act). But you’ll be paying the entire premium-including your employer's share. COBRA is generally not required of businesses with fewer than 20 employees. More COBRA details are on the U.S. Department of Labor website, http://www.dol.gov/dol/topic/health-plans/cobra.htm
You also have the option to shop for insurance in your state’s Health Insurance Marketplace. Experiencing a life event like leaving your job will trigger a special enrollment period of 60 days, when you can shop for, and purchase insurance. For more information about your state’s Marketplace, visit healthcare.gov.
National Coalition for Cancer Survivorship Tool Box (http://www.canceradvocacy.org/resources/publications/insurance.pdf) (PDF)
Georgetown Health Policy Institute: Insurance (http://www.healthinsuranceinfo.net)
Patient Advocacy Foundation: Guide to the Appeals Process (http://www.patientadvocate.org/index.php?p=13)
National Coalition for Cancer Survivorship (http://www.canceradvocacy.org)