Transcript Insurance Rights of Cancer Survivors

Insurance Options for
Cancer Survivors
Phil Kelly
State Health Insurance Benefits
Advisors (SHIBA) in coordination
with Cancer Lifeline
As a melanoma
survivor you often
wonder what
options you have
when it comes to
health insurance.

I had health insurance the first time I was
diagnosed, but what if I have a reoccurrence, will my health insurance cover
it a second time?

The last time was very expensive and I’m
close to my lifetime maximum. Now what?

I’ve just been diagnosed, will my insurance
cover all of the costs?

I am 65 years old and on limited income.
my insurance costs are too expensive.
•
Can I ever change jobs or am I locked
in just to have health insurance?
• Is there any help to pay for
treatment?
• I am exhausted after 6 months of treatment. My
doctor says it’s going to be a minimum of another 9
months of treatment. I don’t know if I can do this
but I have used all of my vacation/sick time and my
insurance comes with my job.
•I have insurance, but I am going to be layed off in
June. Now what?
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The American Cancer Society found in 2008,
approximately 684,850 new cases of cancer
were diagnosed in people under the age of
65 in the United States.
Prior to the recession, 70% of these folks
were estimated to have employer sponsored
health insurance. This number has been
drastically reduced

Across the United States, in 2006, twice as
many people died from lack of health
insurance than died from homicide
Family USA – March 2008
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Cancer treatment is very expensive
sometimes one treatment can exceed $20K

Cancer survivors need long-term treatment
and monitoring

Cancer survivors have the most difficulty
navigating the health insurance system.
Do you have health insurance?

First question asked when you check into a
hospital, doctor’s office, lab, radiation or
infusion center.

You may have insurance through your
employer or association

You may have private insurance that you pay
for totally on your own.

You may have health insurance with a high
deductible or co-pays that you can’t afford =
you are “under insured”.
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You may have insurance through a federal or
state program
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You may not have insurance at all
What are the Health Insurance
options?
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Employers (non-self-funded and self-funded plans).
Other group plans (via associations, organizations,
etc.).
Commercial Insurers sell plans to individuals.
Government sponsors plans (e.g. High Risk Pools,
Medicaid, Breast and Cervical Health programs,
COPES, Medicare, Veterans Administration,
Children’s Health Programs, etc.).
Disclaimer………

This presentation is a quick overview of
what health insurance options exist
today…here and now. It isn’t meant to
endorse one provider over another or
suggest one plan is better. This is solely
prepared to give you information and suggest
you might have some options.

As you all know, things will change in the
coming months to years with the new health
care reform. At this point, we don’t have all
of the information, but at the end I will share
with you what we do know.
Employer-Sponsored Insurance
(Self-Funded Plans)

These plans include large companies who are self insured, have
an insurance administrator, may be a union trust under a union
contract, government plans (Cities, Counties or States) possibly
some church plans.

These plans write their own rules. May or may not require a
“health screening or health questionnaire.”

These plans can provide excellent or more limited coverage.

Each state has an Insurance Commissioner who does NOT have
jurisdiction over self-funded plans. If you have a complaint with a
self-funded plan, call your state’s Department of Labor.

If you have had insurance coverage before for over 18 months
before enrolling in the new plan, then you usually will not have a
pre-existing condition waiting period.
Employer-Sponsored Insurance
(not Self-Funded plans)
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Often are the “Cadillac” of plans available.
Generally, you do NOT have to complete a “health
screen or questionnaire.”
Generally, they do NOT reject you based on health
status.
If you have had previous coverage you may or may
not have a pre-existing condition waiting period.
They are getting a little more “choosey these days!
Employer Plans
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Usually administered by your Human
Resources (HR) department

If you have a complaint or concern, you
should start here.
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COBRA
Many Employer-Sponsored Plans
Offer COBRA When Your
Employment Ends…
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COBRA provides insurance to employees
(and families) when their employment ends.
Companies with 20 or more employees who
offer non-self-funded insurance must by
Federal law offer COBRA.
Some self-funded plans offer continuation of
insurance, like COBRA.
Federal employees are offered something
similar
Who Qualifies?
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An employee who has had a “qualifying
event”
A spouse
Dependent Children
You become eligible to continue coverage
if you are enrolled in your company’s plan,
there is a qualifying event AND it will
cause you to lose your health coverage.
What is a Qualifying Event?

For an employee:
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You either quit or were terminated for
reasons other than gross misconduct
OR your number of hours of
employment were reduced
Qualifying Events for Spouses:
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Voluntary or involuntary termination for
reasons other than gross misconduct
Reduced work hours
Covered employee becomes eligible for
Medicare
Divorce or legal separation of the covered
employee
Death of the covered employee
Qualifying events for Dependent
Children:
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Loss of dependent status under the plan
(usually due to age)
Voluntary or involuntary termination of
employees employment for reasons other
than gross misconduct.
Employee reduce hours
Covered employee becomes eligible for
Medicare
Divorce or separation of covered employee
Death of covered employee
Continue COBRA…
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Your employer or plan administrator will notify you
within 14 days of a qualifying event.

You have 63 days to continue your health
insurance through COBRA and have 45 days after
saying YES to pay the initial premium.
more on COBRA…
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COBRA lasts for 18 months.

It can be extended if you become disabled
under Social Security Disability.

You are then covered for an additional 18 months
(your family members qualify for an additional 11
months)
COBRA is EXPENSIVE!

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Yep, it is, but it is usually cheaper than
individual insurance premiums and cheaper
than paying for cancer treatment out of
pocket!
You are paying group rates and an additional
2% for administrative costs. Qualified
beneficiaries who receive the additional 11
months of coverage may pay up to 150% of
the plan’s total cost.
You MUST pay the premium on the first day
of the period coverage or you could be
DROPPED.
Beyond COBRA
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In many states, once you have completed
your 18 months of COBRA, you can apply to
purchase an individual health insurance plan
and not be required to take a health screen or
health questionnaire.
This is NOT guaranteed if you do not
complete the 18 months of COBRA.
Insurance Offered by Professional
Organizations/Associations
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Insurance can be offered to members of a
particular industry, professional group,
business association, religious or fraternal
organizations.
People who are self-employed and have at
least one employee may be able to join an
association/organization to get insurance, or
may be eligible for a small group plan.
For folks who do not have health insurance I
often ask if they COULD join an association
for group buying power.
Commercial Plans Sold to Individuals
(not via employer or membership in an
association/organization)
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To qualify for these plans, you usually have to
complete a health screening questionnaire.
Many fail it (and are not eligible to purchase the
plan) unless they are young (with limited history
of medical problems).
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Most of these plans have a waiting period for
pre-existing conditions (medical conditions for
which you were treated or for which a prudent
layperson would have gotten treatment).
High Risk Pools
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Offered in 35 states for people who are
considered “medically uninsurable”.
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You have to be turned down by an individual plan
It is very expensive even though it is subsidized
by the state government
Some states limit the number of members with
pre-existing conditions, limit the maximum cap on
annual benefits and have a max on lifetime
benefits
It maybe expensive but the only option for some
cancer patients
Washington State Health Insurance Pool
(WSHIP.gov)
Medicaid
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Provides health insurance to very specific groups VERY complicated system.
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low-income children, parents, pregnant women,
people with disabilities and the elderly
If you are considered a disabled cancer patient (by
Social Security Disability) and are low income you
may qualify for Medicaid.
Benefits are determined based on income and
assets
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If you do not have insurance and are low income, you
should apply.
If your children do not have health coverage, there is
generally programs that will cover them (APPLE)
 This is important b/c you DON’T need ONE MORE medical
bill when you are dealing with cancer.
In addition…
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If you are diagnosed with Breast Cancer and
age 40-64, you should check into the Breast
and Cervical Health Program in your state.
This allows women who are “around” the
200% of FPL or below to have all of their
medical covered at 100%. This is a “fasttrack” on to Medicaid.
They also do cervical and colon screening.
Phone =1-800-756-5437
Social Security Disability
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If your doctor is telling you that you will be off
work for more than 12 month, you should
apply for SSDI.
Make sure the medical records reflect this
statement.
Apply online. Clock is ticking as soon as you
apply
Compassionate Allowances
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Fast Track
Metastatic, stage 4 cancers
Social Security Disability
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Compassionate Allowances
If you are living with metastatic cancer, it is
inoperable or unresectable, you will probably
qualify for a compassionate allowance which
is a fast tract to SSDI.
Can take as little as 3 weeks but often more
like 3 months.
Need to have worked for 10 years (have 40
quarters)
In 2 years you are eligible for Medicare
The 1989 Legislature enacted
RCW 70.170.060, which
prohibits any Washington
hospital from denying access to
emergency care based on
inability to pay, or adopting
admission policies which
significantly reduce charity care.
What is Charity Care?
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Charity care is for low income people and
eligibility is determined by your monthly income
and the number of people in your family
Charity care applies to “appropriate hospitalbased medical services,” but not to services
provided by non-hospital staff.
It covers services within the hospital. It does not
cover physicians services during surgery or
outside of the hospital.
What states have Charity Care or
similar programs?
-Florida
- New Hampshire
-New Jersey
- Virginia
-Indiana
- Washington
-Maine
- New Mexico
-California
- Indiana
-Minnesota
- New Hampshire
-Rhode Island - W. Virginia
- Massachusetts
-Pennsylvania -Oregon
-
- Utah
- Texas
- Georgia
- Idaho
How do I qualify for
Charity Care?
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Income and Family Size
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Income is based on the Federal Poverty levels that
change each April. It looks at the number of people in
your household and the total household income.
Usually you can expect a lot of help if you are at 100%
FPL ($22,050 for a family of 4)
101% - 200%(44,100 for family of 4) FPL –eligible for
some discount
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Consider your income at time of service vs. time of bill
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Hospital must develop sliding fee schedule.
You can apply for Charity Care at anytime.
You become unemployed after your hospital treatment and
now can apply for Charity Care.
Assets may be taken into account.
How to I apply for Charity Care?
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Hospitals provide notice of Charity Care or similar
programs
 Don’t be afraid to ask!
 “ I want to be responsible for my bill, but I can’t afford
to pay it. What kind of help does your hospital have
for low income patients?”
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Don’t let not having insurance prevent you from
going to a public or non profit hospital.
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Ask for the ONCOLOGY SOCIAL WORKER, PATIENT
NAVIGATOR or PATIENT ADVOCATE. Tell them you need
HELP!
A few more things about Charity Care
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If you have Medicare or Medicaid, you need
to use their benefits BEFORE Charity Care
will start. Same if you are “under insured”.
You can apply for Charity Care at any time,
but generally not after your bill is turned over
to collections.
If you are not eligible for Charity Care, ask if
you can make payments, NEVER miss a
payment!
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Don’t be afraid to send even $20 toward your bill. If
the provider cashes the check, they have now entered
into an enforceable contract with you. As long as you
pay, they can’t turn you over to collections.
Veteran’s Administration
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If you served in in the military dating back to
WWI to date you may qualify for medical
through the VA.
Benefits are determine by when you served
and may include: medical, dental, pharmacy,
nursing home.
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This is in inexpensive way to fill Rx.
Contact your local VA office and have your
discharge papers available.
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Plan ahead…you may need a nursing home down
the road.
Medicare
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Medicare primarily provides coverage to
those ages 65 and older
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Individuals under age 65 who are receiving
Social Security Disability Insurance (SSDI)
can be covered by Medicare two years after
they begin receiving SSDI payments.
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Part A, Part B and Part D or a Medicare
Advantage Plan
Medicare Part A…
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The “hospital part” of Medicare. Covers
when you are in the hospital, skilled nursing,
home health, hospice and blood while in the
hospital
Your out-of-pocket is $1,100 (every 61 days)
when you check in the hospital unless you
have a supplemental policy. It covers 20
days of skilled nursing, 100% of home health
and hospice and all but 3 pints of blood.
This out-of-pocket
Medicare Part B
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Cost is $96.40 per month for people earning
less that $85,000. Otherwise =$110/mo
You pay a $155 deductible first
Medicare covers 80% of approved amount for
doctor and durable equipment
Medicare covers 100% of approved lab,
home health and blood (after 3rd pint)
Medicare supplements –AKA
as Medigaps
Medigap plans are private health insurance
policies that provide you with a way to pay for
the gaps in coverage left by Medicare.
 Many, many different options and are
determine by states and counties.
 There are different plans based on need.
 Most important thing to remember:
All Medigaps in each category provide the
same benefits regardless of price.
SHIBA can help you choose which plan is
right for you.
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Medicare Part D…
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The prescription part of Medicare.
Every state offers different plans 1576
nationwide
Costs range from $8.80-$134.80 and Part D
covers
You pay a portion of your Rx costs up to
$2,830 then you reach the “donut hole” and
are 100% responsible for cost until you’ve
paid $6,154, then Medicare cover 95%.
Medicare Advantage Plans
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The Medicare Advantage (MA) plan pays for
all medically necessary care covered by
Original Medicare.
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The MA plan also may include prescription
drug (Part D) coverage, and added benefits,
such as eye and hearing exams, dental care,
foot care, yearly routine exams, and wellness
classes.
Medicare Extra Help
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WA State offers extra help to meet the costs
of Part B premiums.
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There is a federal program to help meet the
costs of Part D premiums and co-pays.
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State Health Insurance Benefits Advisors
(SHIBA) can help you look at insurance
options.
Catastrophic or high
deductible insurance
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While it may be less expensive, it is NOT
recognized as insurance and you will have to
take a health questionnaire if you are
changing plans.
New Health Care Reform – This Year
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Kids will be able to stay on their parents
insurance until age 26
Seniors will get a $250 rebate to help fill the
"doughnut hole" in Medicare prescription drug
coverage
Insurers will be barred from imposing
exclusions on children with pre-existing
conditions.
Insurers will not be able to rescind policies to
avoid paying medical bills when a person
becomes ill.
• Lifetime limits on benefits and restrictive
annual limits will be prohibited.
Cont . Health Care Reform year one
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New plans must provide coverage for
preventive services without co-pays. All plans
must comply by 2018.
• A temporary reinsurance program will help
offset costs of coverage for companies that
provide early retiree health benefits for those
ages 55 to 64.
Businesses with fewer than 50 employees
will get tax credits covering 35 percent of
their health care premiums, increasing to 50
percent by 2014.
Health Reform 2011
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Medicare will provide free annual wellness
visits and personalized prevention plans.
New plans will be required to cover
preventive services with no co-pay.
A 50 percent discount will be provided on
brand-name drugs for Prescription Drug Plan
or Medicare Advantage enrollees.
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So that back those questions…

I had health insurance the first time I was
diagnosed, but what if I have a reoccurrence, will my health insurance cover
it a second time? Assuming you’ve had
this insurance for 9 months, yes it will.

The last time was very expensive and I’m
close to my lifetime maximum. Now what?
Look at WSHIP.org for options or look at
another policy with a higher lifetime max.

I’ve just been diagnosed, will my insurance
cover all of the costs? This really is based
on what type of coverage you have.
Check with the provider.
Do I have to stay in this job for
the rest of my life just so I can
have insurance?
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If you have 18 months of recognized , you
should NOT have to take a health
questionnaire so can transfer to another
insurance company.
When you apply for a new job, you DO NOT
have to tell them that you have had cancer
until you are hired.
I am 65 years old and on Medicare. My
insurance costs are very expensive. Any
options? Yes, if you are on limited income
the State of WA has Medicare Savings plans
Which can help with your Part B premium, your
deductibles and co-pays. The Feds have
extra help for Part D. This is available for
anyone on Medicare regardless of
age…solely dependent on income and
assets.
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Is there any help to pay for tx? Yes, based
on income and assets. Help thru the State and
thru private foundations and organization. See
benefitscheckup.org or call Cancer Lifeline’s
Paying for Cancer program
Advocate Organizations
The
National Coalition for Cancer Survivorship
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http://www.cancercares.org
877.622.7937
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Cancer Lifeline’s Paying for Cancer
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206-832-1282
Will help advocate for you with insurance, bills,
collection agencies, medical providers, etc.
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SHIBA – Statewide Health Benefits Advisors
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1-800-562-6900
Will help with insurance options and issues
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Other places that can help
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Rx help
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Benefitscheckup.org
Needymeds.org
There are foundations that will help with co-pays,
deductibles, premiums.
Call 211for emergency housing, utility help,
transportation, food
Ask to see the social worker or patient navigator
at health care provider.
Get Stuck?
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Call the Paying for Program and leave a
message and we will get back to you ASAP.
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206-832-1285