Insurance Rights of Cancer Survivors
When cancer strikes, you may start thinking about health insurance in a new light. Chances are you will use your health insurance more than ever before. You also may have more problems with insurance than ever before. Don't be alarmed or discouraged, but do be aware.
Types of health insurance
It's important for cancer survivors to have health insurance you can depend on. Many kinds of policies are out there, but not all offer enough protection. It's best to have comprehensive health coverage that will pay for all your basic health care needs. These needs include hospital and doctor care, lab tests, medical equipment, and prescription medicines. When looking at a policy to see if it meets your needs, look at the premium and also consider:
What services are covered
How much you have to pay for covered services
Who gives you care
Be wary of insurance that is not comprehensive. Insurance that’s not comprehensive includes high-deductible or medical savings account (MSA) policies or cancer-only insurance. These are usually not a good deal for cancer survivors.
Getting and keeping private health insurance
You have rights under federal and state laws to help you buy and keep coverage. But these rights are not comprehensive. They may vary depending on where you live, and what kind of coverage you have or seek.
Who regulates my coverage?
To find out about your rights, it helps to know who regulates your kind of health insurance. States regulate many plans sponsored by small employers and most individual coverage you buy on your own. But some coverage is regulated by the federal government. This includes most health plans offered by very large employers. Your protections will vary depending on whether state or federal rules apply. Your protections also will vary depending on whether you are in a group health plan or buying individual coverage on your own.
Your rights under group coverage offered by employers
Employers are not required to offer health benefits at all, or to all employees. If you are offered group health coverage, you have rights under federal and state law. These include:
Nondiscrimination. Your eligibility for coverage under a group health plan cannot depend on how healthy you are now or have been in the past. This means you can't be refused health benefits under an employer's health plan simply because you are a cancer survivor.
Coverage for pre-existing conditions. Sometimes group health plans will temporarily not cover a health condition that you already have when you join. This is called a pre-existing condition exclusion period, or pre-ex. In most cases, group health plans can't impose a pre-ex longer than 12 months. Some states require an even shorter length of pre-ex. Also, when a group plan has a pre-ex, it has to give you credit for past health coverage you had recently.
Under the Affordable Care Act (ACA), insurance companies must offer open enrollment periods when all applicants must be accepted, no matter what their health is. This part of the ACA also prohibits insurance companies from using a person's health status to set insurance premiums.
COBRA continuation coverage. A federal law known as COBRA lets you and your family stay covered under your group health plan when you leave your job or in other cases. Depending on your case, you, your dependents, or both can remain in the group plan for up to 36 months. When you take COBRA coverage, you have to pay the entire premium. This includes the portion the employer used to pay on your behalf.
Your rights under individual coverage
In most states, buying individual coverage can be harder if you are a cancer survivor. This is especially true if it's been less than 5 years since your treatment ended. Where not prohibited by law, insurance companies can turn you down, charge you more, or permanently exclude coverage for cancer, but not all will do so.
The rights you have when buying individual health insurance depend on where you live. State laws vary. Talk with your state insurance commissioner for more information. Or you can get a free consumer guide describing your rights in each state. These are published by Georgetown University and available online.
Sometimes you can get health insurance from the government instead of from a private employer or insurance company. Some public programs are described below.
Medicare is health insurance provided by the federal government. You qualify if you are 65 or older and eligible for Social Security benefits, disabled (regardless of age) and collecting Social Security benefits for 2 years, or on kidney dialysis (regardless of age).
Medicare is divided into parts. Part A covers care you get in a hospital or other facilities. For most people who qualify for Medicare, there is no premium for Part A. You will have to pay a deductible for each hospital stay. Also, for longer stays in a hospital or nursing home, you will have to pay coinsurance. Part B of Medicare covers doctor charges, lab fees, and other outpatient care. You pay a monthly premium for Part B. There is also a deductible for covered services and coinsurance. Part C is a combination of Parts A and B provided by private insurers. These private insurance companies must be approved by Medicare, and must provide all hospital and medical benefits covered by Medicare. These private insurers are called Medicare Advantage. They charge a monthly fee, and some include the Part D prescription medicine coverage. Part C is not available everywhere. Part D is optional. It helps pay for prescription medicines. If you join, you pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescriptions, including a copayment or coinsurance. Costs vary based on which drug plan you choose.
Many people buy private supplemental insurance to pay for costs Medicare does not cover. This coverage is sometimes called Medigap. Some people join private managed care plans that offer Medicare services (Medicare Advantage Plans). Some private managed care plans offer other services like prescription medicines.
Medicare coverage can be very confusing. This is especially true for Parts C and D options. It is best to talk with an independent expert before buying a Medicare Advantage Plan or Medigap insurance. Visit the Medicare website for information on how to select an insurance package that fits your needs.
Medicaid and CHIP
Medicaid is a shared federal-state government program that provides health insurance for low-income people and families. There are specific federal rules that states must meet to get federal funds. Each state has the right to develop its own Medicaid program.
In most states, in addition to having very low income, you must be a child, a parent, an elderly adult, or a disabled person to qualify for Medicaid. Some states do cover low-income adults who aren't elderly, disabled, or parents.
In addition, your state may have a children's health insurance program (sometimes called CHIP) that offers free or subsidized coverage for low-income children. CHIP is part of Medicaid in some states and a separate program in others. Children generally can qualify if their family income is twice as high as the federal poverty level. In some states, children with family incomes as high as 3 to 4 times the poverty level can be covered under Medicaid or CHIP.
You can find state-specific Medicaid and CHIP information by clicking on the States Profiles link.
Other public coverage
Some states offer other help for people who can't afford health insurance. In addition to Medicaid, a few states have other coverage that you can buy at discounted premiums if you have low income. Some states have high-risk pools, where you might be able to buy coverage if a private insurer turns you down. And in some of these states, subsidized premiums are available if you have low income.
Using your health coverage
When you need to use your health insurance, keep these things in mind:
Check your policy to see what rules you must follow. You may need to get permission (a referral) to see a specialist. You might be restricted to a network of doctors or hospital. Going out of network might mean you pay more or your claim is denied. You might need to submit the claim within a certain number of days after the service in order for it to be paid.
Keep good records. This includes copies of all bills and correspondence. Ask for names, addresses, and phone numbers of people you talk to, and note the dates of your conversations.
If a claim is denied, appeal it—again and again if you have to. Ask your doctor to help make your case. Keep records of all your correspondence. And be aware of any time deadlines that might apply. Sometimes you can only appeal a denial within a certain number of days after the decision. In a growing number of states, if you are in a state-regulated plan, you also can appeal to an outside panel of experts. These panels overturn denials about half of the time.
Privacy of your medical information. Some states have laws protecting the privacy of your medical information. These laws vary a great deal. Some laws guarantee you the right to see your medical records, obtain copies, and correct errors. Some prohibit insurers, doctors, hospitals, and others from disclosing information about you to others.
Affordable Care Act enrollment. The ACA has an open enrollment period each year. If you miss that, you may qualify for a special enrollment period. Find out more about ACA insurance here.
March 21, 2017
Fraser, Marianne, MSN, RN,Gersten, Todd, MD