“What Are My Health Insurance Options?”

Healthcare is one of the most significant expenses faced by those living with cancer. If you lack or have insufficient healthcare coverage, we have compiled a list of public and private health insurance providers that may be able to assist you. For a more complete list of resources, please consult Step 10 in this guide.

ERISA (Employee Retirement Income Security Act). This federal law sets minimum standards for most voluntarily established corporate pension and healthcare plans provided for employees.

  1. There have been a number of amendments to ERISA expanding the protections available to health benefit plan participants.One of the most important is the Consolidated Omnibus Budget Reconciliation Act (COBRA), which provides some workers the right to health coverage after job loss. To be eligible for COBRA coverage, you must have been enrolled in your employer’s health plan, and it must still be in effect for active employees. In addition, you must enroll for COBRA continuation benefits.Employers must notify their plan administrators within 30 days after an employee’s termination, or after a reduction in hours causing an employee to lose health benefits. Also, the plan administrator must provide notice to individual employees of their right to elect COBRA coverage within 14 days after the administrator has received notice from the employer. Finally, you must respond to this notice and elect COBRA coverage by the 60th day after the written notice is sent, or the day healthcare coverage ceased, whichever is later. Otherwise, you will lose all rights to COBRA benefits. For further information go to www.dol.gov, or call 866-444-3272.
  2. Health Insurance Portability and Accountability Act (HIPAA). HIPAA is another ERISA amendment; it provides important new protections for working Americans and their families who have pre-existing medical conditions, or who might otherwise suffer discrimination in health coverage based on factors that relate to an individual’s health. For further information go to www.dol.gov, or call 866-444-3272.
  3. Americans with Disabilities Act (ADA). These federal laws are under the jurisdiction of the U.S. Department of Justice and pertain to job discrimination based on disability or disease. For further information go to www.ada.gov, or call 800-514-0301.
  4. U.S. Equal Employment Opportunity Commission (EEOC). This is the U.S. government agency that enforces federal employment discrimination laws. For further information go to www.eeoc.gov, or call 800-669-4000.

Additional programs available through federal or state agencies:

MEDICARE

Medicare is a federal health insurance program available for persons 65 years or older and/or those who have certain disabilities or have end-stage renal disease requiring dialysis.

Medicare consists of two main categories: the Original Medicare Plan and the Medicare Advantage Plan. Each category is made up of four subcategories: Parts A, B, C and D.

The Original Medicare Plan Overview

The Original Medicare Plan consists of Part A, with an option of adding Parts B and D. You will automatically be enrolled in the Original Medicare Plan unless you specifically choose to join a Medicare Advantage Plan (Part C), which operates as a fee-for-service plan. Most individuals will pay a deductible and then a co-pay or co-insurance.

The Original Medicare Plan does not cover everything. Costs that you may incur include co-insurance, co-pays, deductibles, etc. These costs are called gaps, and you may want to consider purchasing a Medigap policy to cover them.

Part A Overview

Part A covers inpatient, hospice and home healthcare. Most individuals do not pay a premium for this coverage.

Part B Overview

Part B covers outpatient care, doctor services, therapists, additional home healthcare and approved medical supplies. Most individuals will have to pay a premium to receive this coverage.

Part C Overview

Part C is the combination of Parts A and B. The main difference between Parts A and B and Part C is that it is offered through private insurance companies approved by Medicare. You may have lower costs and receive extra benefits with this program.

Part D Overview

Part D provides standalone prescription drug coverage insurance, and most individuals pay a premium for it. Plans vary and medication coverage vary, but all medically necessary drugs are covered. Choose the drug plan best suited to your needs.

For additional information, contact the Social Security Administration at 800-772-1213, or go to www.ssa.gov.

MEDICAID

Medicaid is a combination of federal and state programs to help cover medical costs. Eligibility depends on your income and whether you meet specific requirements.

Each individual state determines eligibility and the scope of health services offered. Depending on your state’s rules, you may also be asked to pay a small part of the cost for some medical services.

Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds.

For information about Medicaid, contact the State Department of Social Services or go to www.cms.hhs.gov.

VETERANS ADMINISTRATION (VA)

Veterans Administration (VA) benefits may be available if you or your spouse served in the U.S. Armed Forces.

Acute medical care, medications and long-term care/assistance may be available.

The VA may provide disability payments for Vietnam veterans who have certain types of cancer and/or peripheral neuropathy (from exposure to Agent Orange).

Contact your local VA representative for coverage, benefits and facilities, or call 800-827-1000, or go to www.va.gov.

SPECIAL STATE PROGRAMS

Your state of residence may have special programs or grants for individuals battling cancer. These programs are usually for emergency hospitalization and basic needs.

Contact: Hospital social workers, hospital finance offices and/or your physician’s office manager would likely have the most up-to-date information regarding these programs.

Finally, call your elected representatives either in Washington, D.C., or in your state capital. They may be able to clear up a problem of eligibility for a federal or state program, or recommend an alternative course of action.

PHARMACEUTICAL PROGRAMS

For those who cannot afford their prescriptions, many pharmaceutical companies provide assistance programs. For more information, ask your pharmacist or look online for available programs.

ADDITIONAL HEALTH COVERAGE OPTIONS

A long hospital stay, costly surgery and extended post-operative care can have devastating financial consequences. Extraordinary health events such as these are often referred to as catastrophic care, and there are companies that specialize in providing insurance for these occurrences.

Catastrophic care policies have very limited, or no coverage, for routine expenses like doctor’s visits or prescriptions, and they generally have very high deductibles — the higher the deductible, the lower your premiums. When considering this coverage, it is advisable to weigh the benefit of it against your ability to pay the premium and any deductible.

Some companies also offer long-term care insurance, but there are coverage limitations, caps on total benefit payments, and premiums are costly. Your doctor may be able to help you determine if you are likely to require long-term care of the type covered by this insurance.

If you do not have healthcare coverage, but are physically able to work, consider taking a job with a company that offers open-enrollment health plans.

You also may look to obtain group coverage by joining an association, such as the National Association of the Self-Employed, for example, or a similar membership organization; Rates are generally less expensive than individual policies. Consult an attorney, who can advise you on what you need to do.

COMPLEX CARE MANAGEMENT PROGRAMS

Complex care management programs are designed to support the gravely ill to help them make informed decisions about treatment. These plans typically assign a health advocacy team to help you navigate the healthcare system, advocate on your behalf and explain treatment options and the possible outcomes of each.

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