Insurance Rights of Cancer Survivors

Bobbi Christensen-MeinsProgram DirectorCancer Lifeline

The goal of this presentation is to give you some options on how you make sure you have the resources you need to financially survive your cancer treatment and beyond….

So what’s new???

WASHINGTON HEALTH Offered by Community Health Plan of

Washington. This is a good option for folks who can no

longer afford COBRA or are uninsured. Monthly premiums are affordable Based on ONLY 3 things: Which WA county do you live in? How old are you? Do you smoke? Oh…well really 4 things…are you in jail or prison?

Washington Health

A network plan that includes MANY Washington oncologists, surgeons and hospitals.

Each year you purchase either $75K or $100,000 of health insurance. Average chemotherapy costs per year (not

transplants or radiation) Breast Cancer = $20,964 Lung Cancer = $39,891 Prostrate Cancer = $41,134

Washington Health

If you have had 90 days of credible coverage you do not have to take the health questionnaire.

$500 deductible pp ($1500 for family) Annual out-of-pocket = $3,000 Co-insurance = 30% in network/50% out of

network Rx = generic=$10, name brand/non

formulary = 50%

Washington Health Premiums

$419.02 $403.56 Adult (65 and older)

$298.25 $287.44 Adult (60-64)

$264.88 $255.35 Adult (55-59)

$228.34 $220.21 Adult (50-54)

$191.79 $185.07 Adult (45-49)

$167.96 $162.15 Adult (40-44)

$153.65 $148.40 Adult (35-39)

$140.94 $136.18 Adult (30-34)

$125.05 $120.90 Adult (25-29)

$115.52 $111.73 Adult (to age 24)

$78.34 $75.98 Child (Dependent up to age 22)

Health 100Health 75Age Bracket

Living in King County, you don’t smoke and you aren’t in jail.

New Health Care Reform ActHere’s what we know today

If you have insurance now through your job, your health plan will probably stay the same but we anticipate costs to increase.

If you are too sick to work or are laid off, it will be easier to stay insured. You can’t lose insurance b/c you have cancer and

are racking up huge bills. Out-of pocket fees will be capped so you don’t

have to choose between Tx and making you house payment or rent.

Health Care Reform Act THIS YEAR Kids will be able to stay on their parents insurance

until age 26. Seniors who spend $940 in Rx will get $250

rebate. Next year will get 50% off brand name Rx Insurance Companies can’t exclude kids with pre-

existing conditions Insurers will not be able to rescind policies to

avoid paying medical bills when a person becomes sick

Lifetime limits on benefits and restrictive annual limits are prohibited.

Continue This Year of Health Reform

New plans must provide coverage for preventive services w/o co-pays. All plans must comply by 2018.

A temporary re-insurance program will help offset costs of coverage for companies that provide early retiree health benefits for those ages 55-64.

Businesses w/ fewer than 50 employees will get tax credits covering 35% of their H.I. Pre-miums, increasing to 50% by 2014.

Health Reform in 2011 as we know it today…

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% discount on name brand drugs for Medicare Part D and Medicare Advantage plan enrollees.

Kasier Family Foundation has a breakdown of the entire program year-by-year

http://www.kff.org/healthreform/8060.cfm

What are the Health Insurance options?

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.).

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) possiblysome 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)

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 Usually administered by your Human

Resources (HR) department

If you have a complaint or concern, you should start here.

COBRA

Many Employer-Sponsored Plans Offer COBRA When Your

Employment Ends…

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? 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:

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:

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:

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…

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…

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! 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 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

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)

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).

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).

Medicaid

Provides health insurance to very specific groups -VERY complicated system. 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 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.

High Risk Pools Offered in 35 states for people who are

considered “medically uninsurable”. 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)

In addition… 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 “fast-track” on to Medicaid.

They also do cervical and colon screening. Phone =1-800-756-5437

Social Security Disability 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 Fast Track Metastatic, stage 4 cancers

Social Security Disability 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? 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 hospital-based 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 - Utah-New Jersey - Virginia - Texas-Indiana - Washington - Georgia-Maine - New Mexico - Idaho-California - Indiana -Minnesota - New Hampshire-Rhode Island - W. Virginia - Massachusetts -Pennsylvania -Oregon

-

How do I qualify for Charity Care?

Income and Family Size 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 Hospital must develop sliding fee schedule.

Consider your income at time of service vs. time of bill 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? 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?”

Don’t let not having insurance prevent you from going to a public or non profit hospital. Ask for the ONCOLOGY SOCIAL WORKER,

PATIENT NAVIGATOR or PATIENT ADVOCATE. Tell them you need HELP!

A few more things about Charity Care

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!

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 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. This is in inexpensive way to fill Rx.

Contact your local VA office and have your discharge papers available. Plan ahead…you may need a nursing home down

the road.

Medicare Medicare primarily provides coverage to

those ages 65 and older

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.

Part A, Part B and Part D or a Medicare Advantage Plan

Medicare Part A… 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 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

i h f

Medicare Part D…

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

The Medicare Advantage (MA) plan pays for all medically necessary care covered by Original Medicare.

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

WA State offers extra help to meet the costs of Part B premiums.

There is a federal program to help meet the costs of Part D premiums and co-pays.

State Health Insurance Benefits Advisors (SHIBA) can help you look at insurance options.

Catastrophic or high deductible insurance

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.

Advocate OrganizationsThe National Coalition for Cancer Survivorship http://www.cancercares.org 877.622.7937

Cancer Lifeline’s Paying for Cancer 206-832-1282 Will help advocate for you with insurance, bills,

collection agencies, medical providers, etc.

SHIBA – Statewide Health Benefits Advisors 1-800-562-6900 Will help with insurance options and issues

Other places that can help Rx help 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?

Call the Paying for Program and leave a message and we will get back to you ASAP.

206-832-1285