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Triage Cancer’s Quick Guide to Health Insurance: Employer-Sponsored & Individual Plans

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Triage Cancer’s Quick Guide to Health Insurance: Medicare

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Health & Disability Insurance

This video was originally published by LiveStrong on February 10, 2010, here.

Those affected by cancer need to understand health and disability insurance. This is an overview of things you need to know under current laws. To learn more, consult with those knowledgeable about insurance matters. If you are working, talk with your employer’s benefits coordinator and the insurer.

There are often changes in how people in the United States receive health care coverage. Some of these changes may benefit people affected by cancer. To learn more and stay up to date, visit HealthCare.gov. Also, the LIVESTRONG Cancer Navigation Services offers guidance about insurance and other cancer-related issues.

If You Have Health Insurance

1. Read your policy to learn what is covered and not covered. Talk with the insurer to get answers to your questions. You also need to understand what the plan requires. For example, there may be certain limits on when you are allowed to submit insurance claims or to appeal claim denials.

If you do not have a copy of your insurance policy, ask the insurer for another. You do not have to tell the insurer about your cancer diagnosis at the time you request the copy.

2. Continue to pay the full amount of your insurance premiums on time. This will keep your health coverage active. An insurer cannot deny benefits for covered medical services when your policy is active. If you do not pay the full premium on time, your policy will be closed (or lapse). If your policy is closed, health coverage will stop.

After a cancer diagnosis, it can be very hard to find new coverage if an existing insurance policy lapses. If a new policy can be purchased, it will likely cost much more and have longer waiting periods. It may also exclude certain benefits due to medical history.

What to Think About in a Health Insurance Plan

3. Follow all of the insurance plan’s rules. For example, many insurance plans require that you contact them to get specific medical services pre-approved. This means that your health care provider’s office should contact the insurer before sending you for tests or other treatment.

Make a list of all your current health care needs. Include services and treatments that you may need in the future. Compare your health plan benefits to expected medical needs. This will help you decide whether you already have the coverage that you need.

If You Don’t Have Health Insurance

Begin to look for ways to find coverage if you have concerns about having no health insurance. Check out options such as:

  • Group insurance through a union or as a member of another group.
  • An individual health insurance policy that you buy for yourself.
  • Federal or state benefit programs that are based on your income and disability.
  • Services through county, community and hospital programs.
  • Insurance coverage under the health plan of a loved one.
  • A new job that offers group health coverage.
  • The insurance options finder tool at finderhealthcare.gov.

Types of Insurance Coverage

Group health plans are offered through groups with employees or members such as:

  • Employers.
  • Credit unions.
  • Labor unions.
  • Trade groups.
  • Organization or association groups

These plans cover a large group of people. The insurer cannot refuse to insure any members of the group health plan. However, health conditions that existed before enrolling in the plan (called pre-existing conditions) may not be covered right away. This is defined by the policy.

Individual health plans are purchased by one person. The cost is usually much higher than group plan coverage. This type of plan may not cover certain pre-existing health conditions. When you apply, the insurer will review your medical history and decide what a plan will cost. They may decide not to sell the health coverage to you.

How to Find Out About High-Risk Pool Coverage

High-risk pools—Many states have organized private, self-funded insurance coverage offered through high-risk pools. These are plans for people who have not been able to get other insurance. Proof of this inability to get other insurance may be required when you apply such as copies of denial letters from insurers. The National Association of Health Underwriters (NAHU) offers a consumer guide to high-risk health insurance pools.

Laws that Affect Health Insurance Coverage

Be sure to keep your health insurance if you have it. If you lose your insurance, it may take time or cost more to purchase another health policy. Three important laws affect health insurance coverage.

Affordable Care Act of 2010 puts health insurance reform into effect over a period of years. The following changes in insurance coverage may help people affected by cancer:

  • Private insurance companies cannot deny coverage to children (under age 19) with pre-existing conditions such as cancer.
  • Health plans cannot drop a person from coverage when they become sick.
  • No lifetime dollar limits on coverage through individual and group health insurance plans.
  • Young adults can be covered under a parent’s insurance policy until they reach age 26.
  • Seniors with Medicare benefits to receive discounts on brand drugs by 2013. The coverage gap will be closed completely by 2020.
  • High-risk insurance pools set up in every state to provide coverage for the uninsured.
  • Medicare and new private health plans will cover preventive services (like breast, cervical and colorectal cancer screening) with no co-pays and deductibles.

For more information and updates about the Affordable Care Act, visit healthcare.gov.

Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) is a federal law that provides the right to continue health benefits for a certain amount of time after leaving a job. The former employee must sign up within a certain time frame and pay the full premium amounts. It also applies to loved ones who were covered by the employee’s health insurance plan.

If you know that you will be leaving your job:

  • Talk with your employer’s benefits department. Find out how and when leaving your job will affect your health benefits.
  • Learn about the COBRA coverage that will be offered when you leave your employer. Ask how much it will cost.
  • Find out about the dates for signing up and for making payments. Pay the full amount on time every month.
  • Ask when COBRA payments will start and how long the health benefits will last.
  • If needed, ask if you can get insurance benefits beyond the initial COBRA coverage period. Some plans allow this in certain cases.
  • Find out if your state offers insurance programs or other ways to keep your health insurance after COBRA.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law. It protects those covered by group health insurance plans. It limits the length of time a group plan insurer can refuse to cover pre-existing health conditions. It also protects personal privacy.

Under HIPAA, you may be able to keep health coverage if you go from one group plan to another. For example, if you change employers, the new group plan must cover a pre-existing medical condition without an exclusion period if:

  • You have had health insurance with no gaps in coverage for longer than 63 days and
  • You have had health insurance for at least the previous 12 months

HIPAA does not protect the coverage provided by individual health plans. If you try to change to a different individual plan, the new insurer can legally turn you down.

Some states have health insurance protection laws that are similar to federal laws. Check to see if your state has laws that can help you get or keep health coverage. Read more about HIPAA protections at hipaa.com.

Disability Income Insurance

Group and individual disability income plans provide benefits if you are not able to work. There are two types of disability policies:

  • Short-term policies pay a weekly income benefit for a short period, such as up to two years.
  • Long-term policies pay income benefits for the time specified by the policy. This could be as long as the rest of a person’s life. It might be up to the age when a person can retire (65 or 67).

Some employers offer short-term disability insurance. The income benefits start soon after you cannot work. They may continue until long-term benefits start. Even if you become unable to work, pay the full insurance premium on time. Keep paying until you get a written notice to stop. If you do not pay, the insurer will cancel your policy.

Long-term benefits continue as long as you are disabled. The insurer will review your case regularly. Benefits will stop if you go back to work. They will also end if a health care provider informs the insurer that you are no longer disabled.

Dealing With Insurance and Benefit Claim Denials

Always look into insurance and benefit claim denials. If you are denied benefits, you may need to appeal the insurer’s decision. An appeal must be filed within the time allowed by the insurer.

You or someone else may have to advocate or fight for your rights. Ask the insurer to answer your questions about the denial decision. Use all of your appeal options. If you believe that a claim denial is unfair, contact an advocacy organization for help such as:

As you go through treatment, you will need to share information with insurers and health care providers. If you are not feeling well enough to do this, ask someone you trust to help. He or she can keep track of insurance applications, claims, payments, denials and appeals. Your health care provider can also refer you to a social worker for help.

If you have questions about an insurance denial, an appeal or your rights, you can contact the Employee Benefits Security Administration. They are part of the U.S. Department of Labor and will offer free, confidential assistance.

How Medicare Covers Cancer in 2019

Cancer is a much more common disease than we’d like to believe. According to the National Cancer Institute, 38.4% of the people in the United States will be diagnosed with some kind of cancer during their lifetime – that’s 125,068,800 people out of our current population.

Some of the most prevalent forms of cancers among seniors are breast cancer, colon cancer, and lung cancer. Because aging can bring a higher risk factor for certain cancers, it’s important you know how well Medicare covers cancer. Fortunately, Medicare covers cancer quite well.

Common Cancer Treatments and Services

First, let’s talk about treatments and services that most cancer patients receive. This will help you to understand how specific procedures are covered under Medicare. Below is a short list of treatments, services, procedures, etc. that cancer patients may receive.

  • Chemotherapy
  • DME (durable medical equipment)
  • Hospice
  • In-patient hospital stays
  • Medications
  • Oncologist visits
  • Radiation
  • Skilled Nursing Facility (SNF) care
  • Surgery

It’s true that Medicare covers most treatments, procedures, and services needed for managing cancer, but you need to know more than that. You should learn how each service is covered and how much you’ll pay for it.

While it’s hard to know for sure how much you will pay down to the cent due to certain factors, you can at least get a ballpark estimate of what you can expect to spend.

Medicare Part A Coverage

In short, Medicare Part A covers your in-patient hospital stays. In addition, stays at an SNF and hospice care are also covered under Part A among a few other things.

This may not seem like much for an entire part of Medicare to cover; however, if you think about how expensive these services are, it’s easier to understand. Also, depending on how recently you have left the hospital, there are times that Part A could cover things like DME and home health care too.

Costs Under Part A

Like all other parts of Medicare, Part A has a deductible. However, you will soon learn the Medicare Part A deductible is unlike any other deductible in Medicare. Most deductibles are annual; however, Part A’s deductible is per benefit period.

What this means is that if you go to the hospital multiple times a year, you could experience multiple benefit periods, and that means you could pay the Part A deductible more than once a year. As of 2019, the Part A deductible is $1,364.

The $1,364 deductible pays for your first 60 days in the hospital. If you stay in the hospital for more than 60 days, you will owe a daily copay. The daily copay for Part A start at $341 and increases to $682 after day 90.

The deductible also covers your first 20 days in an SNF if your doctor sends you to one to finish out your recovery. If your SNF stay is longer than 20 days, you will pay a daily copay of $170.50.

All costs after 150 days in the hospital or 100 days in an SNF are your responsibility.

Medicare Part B Coverage

Medicare Part B covers your outpatient services, treatments, procedures, and then some. They even cover some things while you’re in the hospital. Things like chemotherapy, radiation, surgery, and oncologist visits are all examples of things that can be covered under Part B.

Costs Under Part B

Medicare Part B has a monthly premium that is based on your income. Most people pay $135.50 each month in 2019 for Part B. The annual deductible for Part B in 2019 is $185.

Once you have paid your deductible, Part B will cover 80% of the cost for Medicare-covered services and treatments, like the ones listed above. The other 20% of the cost is your responsibility. Sometimes you can incur Part B charges while you are in the hospital, such as when a physician performs an outpatient surgery or you are using a hospital facility to get a diagnostic imaging scan, which is covered under Part B.

Let’s look at an example. Joe goes to the hospital for a minimally invasive surgery. He stays in the hospital overnight for observation. He will pay his Part A deductible of $1,364, his Part B deductible of $185, and 20% of the cost for the surgery and any other Part B services provided to him while in the hospital.

Medicare Plans That Can Help

Just from that one surgery, Joe could be paying thousands of dollars out-of-pocket. However, if he had a Medicare plan, he could be better protected from having to empty out his wallet.

Medigap Plans

Medicare Supplement plans, also known as Medigap plans, help cover the patients from having to spend so much out-of-pocket. A Medigap plan could potentially eliminate all of the costs that Joe would normally have to cover himself.

A few Medigap plans that could help Joe immensely are Plan F, Plan G, and Plan N. Plan F would cover everything mentioned above, while Plan G would cover everything except the $185 Part B deductible.

Most people only get one opportunity to enroll in a Medigap plan with guaranteed approval. So, if you have been diagnosed with cancer before becoming eligible for Medicare, you should enroll in a Medigap plan during this one-time open enrollment window.

Medicare Advantage Plans

Because Medigap plans usually have a higher premium, some people elect a Medicare Advantage plan instead. As long as you have one or the other you will be able to have extra coverage.

Medicare Advantage plans provide extra coverage in a few ways such as providing additional benefits, offering lower copays, and including a maximum out-of-pocket. In 2019, the set maximum out-of-pocket spending limit is $6,700 for in-network services.

This means, even if you can’t afford a Medigap plan, you will at least be covered from spending more than $6,700 for in-network services in any given year.

It takes some research to decide whether a Medicare Advantage or Medigap plan is the right fit for you, so make sure you learn how each type of coverage works before you choose a plan.

Medicare Part D Coverage

Part D is the part of Medicare that is in charge of your drug coverage – well, most of it anyway. There are some cases in which Part B would cover your medications, but we will get into that in a little bit.

Costs Under Part D

Each Part D plan has a premium. Currently, the national average for Part D monthly premiums is $35. You also have an annual deductible included in your Part D drug plan. In 2019, the maximum deductible a plan can set is $415.

After you have met your deductible you will move into the second stage of your Part D plan called the initial coverage stage. During this stage, you will pay copays for drugs covered under your plan. The copay you pay for any given drug depends on the tier the plan has the drug classified as.

After you and the carrier together have spent $3,820, you will move into the coverage gap. During this stage, you will pay a specified percentage depending on what type of drug it is, brand-name or generic.

Once your out-of-pocket spending hits $5,100, you’ll move into the catastrophic coverage stage which is the stage you will remain in until January 1st. In the catastrophic coverage stage, you will pay no more than 5 percent of your drug costs.

Drugs Covered Under Part B

Medicare Part B covers medications that are administered to you in a medical office setting. For example, chemotherapy is administered to you, therefore, Part B covers it, not Part D.

Think of Part D as your drug coverage for prescriptions you pick up at the pharmacy yourself. However, even Part B covers some of those.

Better Safe Than Sorry

We hear all the time, unfortunately, of how someone didn’t get Medicare Part D when they were first eligible because they weren’t taking any medications at that time. Well later, come to find out, they have been diagnosed with cancer and now must wait until the fall election period to enroll in a Part D drug plan.

Since they waited, not only will they have a lifelong late penalty tacked onto their premium, they have to pay 100% out-of-pocket from their medications until they get enrolled in a plan.

The potential of being diagnosed with cancer is also a reason why you should enroll in a Medigap plan when you are first eligible. Like we mentioned earlier, if you wait until it’s too late, you will be denied coverage due to your diagnosis. It’s always better to be safe than sorry.

 

Facts About Medicare You Didn’t Know

If you or a loved one are approaching the 65-year-old mark, it’s time to get serious about Medicare. There are a lot of things to look forward to as you get older (and wiser), and Medicare can be one of them if you take the time to understand the program and how you can benefit from it.

Unfortunately, a lot of confusing misconceptions surround Medicare. This leaves people unsure of how to make the best choice for them. Luckily, we have all the best facts you didn’t know about Medicare from a licensed HealthMarkets agent who knows the program inside and out. Keep reading to make sure you have the right coverage when you reach Medicare years.

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Medicare is Not Free Insurance

The most common misunderstanding about Medicare is that it is free insurance sponsored by the government. Like all health insurance in the United States, you have to pay premiums for Medicare Part B, Medicare Advantage, and supplemental coverage. The good news is that the government secures costs for Medicare Part B based on your income. The standard premium for Part B in 2018 is $134 assuming your income is under $85,000 as a single taxpayer or $170,000 for joint returns.

If you receive social security benefits, this can help cover the costs of Medicare premiums. For those who opt for Medicare Parts C and D or any supplemental coverage, you have more freedom in the price depending on the plan you choose.

Medicare Will Not Cover All Treatment

Once again, like most traditional health insurance, Medicare will not 100% cover all health costs. Inpatient services involve a deductible over $1300, and you’ll need to pay a fee per day for any coverage in a facility for over 60 days. With Medicare Part B, you’ll need to still pay 20% of the Medicare-approved amount for care, and this is in addition to your annual deductible.

The best way to prepare for the costs of treatment is to do your research. If you know there are certain prescription drugs you’ll need or special doctors you’d prefer to visit, consider a Medicare Part C plan which gives you more freedom in coverage.

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There is a Deadline to Sign Up

The best time to sign up for Medicare is when you turn 65. This is called the Initial Enrollment Period, and it begins 3 months before you turn 65. It continues for another 3 months after your birthday. If you miss this initial period, you’ll face deadlines if you choose to join later. You’ll also be limited to enrolling during the specific open enrollment times during the year, which could lead to limited coverage.

There are a few exceptions to this rule. First, if you already receive social security benefits, you are automatically enrolled in Medicare on your 65th birthday. Also, if you’re still working and covered by your employer, there are different options. When in doubt, speak to an advisor at your local Social Security office for the specifics of your situation.

You Might Need Supplemental Coverage

Medicare is a great program, but there’s a list of things the program does not cover. Things like long-term care, hearing aids, dental care, or even eye exams are often not covered under Medicare. This is why many seniors opt for a Medigap policy to include extra coverage for these gaps in treatment. Talk to your doctor about what you’ll likely need coverage for in the upcoming years, and prepare yourself with the right additional policy, as needed.

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You Have Access to Preventative Care

While you’ll likely need to pay for treatment and complex health services, you receive a wide array of preventative care for free. It’s always a good idea to take advantage of these services to stay on top of your health as you age.

The most comprehensive option is the annual wellness visit which includes a personalized prevention plan. Every 5 years you’ll have access to a free cardiovascular screening, and annually you can get a flu shot and routine cancer screenings. The sooner you’re able to catch a potential problem, the less expensive and complicated it will be to treat.

It’s vital you take your health seriously as you age. It’s important to understand that while Medicare covers much of your health care, it does not cover everything. You’ll also need to follow the enrollment rules to take advantage of the program’s benefits. Knowing what Medicare is and is not will help you decide on the right coverage when it matters most.

The best way to prepare for the costs of treatment is to do your research. If you know there are certain prescription drugs you’ll need or special doctors you’d prefer to visit, consider a Medicare Part C plan which gives you more freedom in coverage

Health Insurance and Cancer: Your Mileage (and Coverage) May Vary

Financial toxicity is the phrase used to describe the impact of the cost of treatment on patients. The NIH describes financial toxicity as “problems a patient has related to the cost of treatment.” No matter what kind of health coverage plan you have, if you get a cancer diagnosis you’ll quickly discover all the things you’ll have to pay for, from co-pays on chemotherapy infusion drugs to the intricacies of “co-insurance,” where an insurer will pay a percentage, usually 70-80%, of the cost, with the patient responsible for the remaining percentage.

Financial toxicity isn’t limited to cancer – ask any person with diabetes who relies on insulin to stay alive about that – but the cost of cancer treatments is high, and rising higher. Cancer patients are put in the position of having to decide whether they’ll get the treatment their oncology team prescribes, or if they’ll put it off until they have the money for it. Patient assistance programs at pharmaceutical companies can offer some help, but there is no guarantee that a patient assistance program for a specific cancer drug will help everyone who can’t afford the drug.

An NPR piece covered this last year, framing the story around a man with advanced lung cancer whose oncologist prescribed a new drug, Alecensa, for his treatment. Alecensa’s annual list-price cost is $159,000, with Medicare patients like the man in the NPR piece paying $3,200 per calendar year. The patient in the story was prescribed the drug in late 2016, but decided to forego filling the prescription until January 2017, to avoid having to pay $6,400 within 60 days for the treatment.

This is part of a pattern of cost shifting across the health payment landscape. Premiums for private insurance rose 170% from 1999 to 2011, far higher than the average increase in wages in the same time frame. Prescription co-pays also rose dramatically with the introduction of tiered drug coverage plans that passed more cost to the patient. For example, from 2000 to 2012, the proportion of individuals with a drug plan that had three tiers increased from 27% to 63%.

Exacerbating the immediate financial anxiety of negotiating for a treatment that could mean the difference between life and death, there’s the impact of medical bills on a patient’s long-term financial health. A Consumer Financial Protection Bureau report in 2014 revealed that almost 20% of credit reports had medical debt reported on them. In 2016, the Commonweath Fund noted that, “As of late 2016, 28 percent of U.S. adults ages 19 to 64 who were insured all year were underinsured — or an estimated 41 million people. […] Half (52%) of underinsured adults reported problems with medical bills or debt and more than two of five (45%) reported not getting needed care because of cost.”

I’ll put a face on this issue by introducing you to a friend of mine, Linnea Olson, who has been successfully beating Stage IV lung cancer for over a decade. Linnea has insurance coverage under COBRA, which is costly, but helps keep her alive by covering the costs of treatment that aren’t covered by the clinical trials she’s been part of over the years. She recently got a notice that her insurance had been terminated – the story on that is here, on her blog – which put her in the “high anxiety” zone, to say the least. That post is a very clear example of how financial toxicity impacts someone with cancer. Her situation lit fires across the cancer patient activist community, launching a campaign to get her coverage back. Four days later, she received word that her coverage had been reinstated. She shared that news publicly on her blog, too.

My point here is that this should not be way Americans are expected to deal with a cancer diagnosis – by facing the fight of their life while their financial lives are laid waste. The costs of treatment shouldn’t be the first thing someone has to think of when facing a life-threatening illness. The patient community is in sync on that. The oncology clinical community agrees that treatment costs, and financial toxicity, are in need of clearer discussion. The American Society of Clinical Oncology published a report in 2017 that included a recommendation that discussion of treatment cost and coverage “would […] facilitate rational discussions of efforts to use more cost-efficient regimens, use less expensive alternatives, or perhaps forego extremely expensive and toxic options that have little chance to provide meaningful benefit.”

I recommend that we keep advocating for more transparency in insurance coverage, and in the in-clinic discussion of the costs and benefits of cancer treatments. It also couldn’t hurt to advocate that our elected representatives craft legislation that makes that transparency a requirement, not an option.