- Children Diagnosed With Cancer: Financial and Insurance Issues
- Insurance is complicated
- Private health plan coverage for children
- How to manage your child’s health insurance
- Getting answers to insurance-related questions
- Keeping records of your child’s insurance and medical costs
- Handling a health insurance claim denial
- Keeping employer-sponsored health insurance coverage when you leave your job
- What if my child’s medical care is covered by more than one insurance company?
- Government-funded health plans
- Who regulates insurance plans?
- Options for uninsured children
- State coverage and health insurance options for the hard to insure
- What sources are available to help with treatment costs if my child doesn’t have insurance and there’s no public assistance available?
- Financial issues for families: Getting help with living expenses
- To learn more
Keeping employer-sponsored health insurance coverage when you leave your job
There are federal laws which give people the chance to continue employer-sponsored medical insurance coverage (including for their children) when a person has a qualifying event (defined below in the COBRA section).
COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986)
COBRA gives you, your spouse, and/or your dependents the right to keep your health insurance coverage at the employer’s group rates. But because the employer usually covers a portion of the plan cost when you’re employed, you usually pay much more than while employed. You must now pay the portion that your employer paid plus a small administrative fee. In most cases, you can keep the insurance for up to 18 months. Some people may be able keep it for their child a few months longer.
In 2014, the new health care law will offer the option to purchase new coverage through health insurance marketplaces (which may have different names in different states and are also called “exchanges”). These plans may offer more affordable coverage options for you and your family than an employer plan through COBRA. See “The health care marketplace – finding individual plans for 2014 gets easier” in the section “Private health plan coverage for children.”
For 2013, and for those who may not want to use the health insurance marketplace, COBRA is available when coverage would normally be lost because of qualifying events, such as
- Stopping work
- Reducing work hours
- Divorce or legal separation
- The covered person is able to get Medicare
- A dependent child is no longer considered to be dependent according to the terms of the plan
- Death of the employee
How long COBRA allows people to keep their group medical insurance depends on the qualifying event. For example:
- Up to 18 months of continued coverage is allowed if you stop working or reduce the number of hours you work.
- 29 months of coverage is possible if a beneficiary is considered disabled. (This determination of disability is made by the Social Security Administration.)
- 36 months of coverage is available for the spouse or child in cases of divorce or legal separation, the covered person becoming eligible for Medicare, death of the employee, or when a dependent child is no longer considered to be a dependent.
If a person is fired for gross misconduct, he or she is not eligible for COBRA – and neither are the children or spouse.
COBRA is not given automatically but must be chosen by the former employee or beneficiary within 60 days of getting the written COBRA “election notice” (this is not always within 60 days of when you stopped working). The employer must notify an employee in writing that COBRA is available after work is stopped or hours are reduced. If you elect to keep your and your dependents’ insurance through COBRA during that 60 days, it will retroactively cover back to the date the insurance ended.
But there’s also a deadline for notifying the plan administrator of qualifying events that don’t directly involve the employer, which varies according to the qualifying event. Whose responsibility it is to notify the plan administrator also depends on the qualifying event. In cases of family changes, the beneficiary must do it, for instance, in these situations:
- Legal separation
- An employee’s child reaches the status of non-dependent
- The employee becomes eligible for Medicare
This means it may be the employee, the employee’s spouse, or the employee’s adult child who needs to notify the plan administrator of a qualifying event. If this notice is not given within the deadline, the spouse or child may lose their COBRA rights.
If coverage for dependent(s) is ending for any of these reasons or because of the employee’s death, their coverage may be continued for up to 36 months. Contact the employer’s human resources person, the insurance company, or check the policy to find out the details of what must be done and who should do it.
You can keep your health insurance 1) if the premium is paid, 2) until you, your child, or your spouse becomes covered under another group policy, and 3) only up to a certain time limit. Premiums cannot be above 102% of the cost of the plan for employees in similar situations who have not had a “qualifying event.” COBRA coverage may be lost if your former employer stops offering all health plan coverage.
COBRA is overseen by the US Department of Labor and they can give you more detailed information on how it works. (See the section called “To learn more.”) Families often are concerned about being able to pay the premium for COBRA. If this is the case, talk to your team social worker who may have suggestions about how to help with these costs.
For more details, read our document called What Is COBRA?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
This is a federal (US) law with many clauses that can help parents of children or teens with cancer:
- It allows a parent who has had health insurance for at least 12 months with no long loss of coverage (usually more than 63 days) to change jobs and be guaranteed other coverage with a new employer (as long as that employer offers group insurance). In this case there may be no waiting period and the pre-existing condition exclusion may be reduced or not applied.
- For dependent children and many young adults up to age 26, there are new protections under the Affordable Care Act that do not allow pre-existing condition exclusion periods. This protection applies to children and young adults up to age 26 who haven’t had a lapse in coverage longer than 63 days. (See the section called “The Affordable Care Act of 2010” in the section “Options for the uninsured” for more information.)
- HIPAA requires insurers to renew coverage for all employers and individuals as long as premiums are paid on time.
- HIPAA also guarantees that group insurance coverage is available for employers with 2 to 50 employees. But it doesn’t require these small employers to buy and offer the insurance to their employees.
- HIPAA helps protect anyone left out of group health coverage after COBRA has run out. If you are eligible and act within 63 days of losing COBRA coverage, HIPAA guarantees that you can buy some type of coverage and that you will have a choice of at least 2 options. But it’s important to know that no one will notify you that you are eligible or of the 63-day time limit. Contact your state insurance department or commission to find out what’s available to you, or call us.
The Affordable Care Act now governs some of the issues and limitations that were under HIPAA before. For more information about HIPAA visit our website or call and ask for What Is HIPAA? You can also contact your state department or commission of insurance. Go the “To learn more” section for contact information.
The Family and Medical Leave Act of 1993
The Family and Medical Leave Act (FMLA) requires employers with at least 50 employees to provide up to 12 weeks of unpaid, job-protected leave for eligible employees for certain family and medical reasons. Having a child with cancer is certainly a reason to take family leave.
Employees are eligible if they have worked for a covered employer for at least 1,250 hours in the previous 12 months. For the time period of the FMLA leave, the employer must maintain the employee’s health coverage, including coverage for dependents.
Your child’s pediatric oncologist and the team social worker can help with the paperwork your employer needs for FMLA leave.
This act is regulated by the US Department of Labor’s Wage and Hour Division. They can give you more information. Check your local phone book under US Government, Department of Labor for contact information or find it in the “To learn more” section. Also, our document called Family and Medical Leave Act (FMLA) can give you more details on this option.
The Americans With Disabilities Act of 1990
The Americans With Disabilities Act (ADA) helps to protect anyone who has, or has had, certain disabilities, including cancer, against discrimination in the workplace. Parents of dependent children with cancer are also protected under this law.
The ADA requires private employers who employ 15 or more people, labor unions, employment agencies, and government agencies to treat employees equally, including the benefits offered them, without regard to their disabling condition or medical history. It also does not allow employers to screen out potential employees who have children with disabilities.
This Act, along with the Health Insurance Portability and Accountability Act (HIPAA), makes it easier for a parent to change jobs and move from one group insurance plan to another. This law is overseen by the US Equal Employment Opportunity Commission (EEOC). They can answer questions and give you more information by phone at 1-800-514-0301. You can also get more details in our document called Americans With Disabilities Act: Information for People Facing Cancer.
The Affordable Care Act of 2010
Many people are afraid they will lose their health coverage and their family’s coverage if they lose their jobs. Some face dollar limits on the amount of care their health plan will cover. The Affordable Care Act (ACA), passed in 2010, changes health care in many ways that help families with cancer.
The ACA has been phasing out the use of annual dollar limits and in 2014 it bans them for most plans. These limits apply to all employer plans and all new individual market plans. You’ll need to check your plan materials to find out when your health insurance plan was last issued or renewed to find out if it’s “grandfathered” and whether these rules apply to it:
- Plans issued or renewed beginning September 23, 2010 have not been allowed to set annual limits lower than $750,000.
- The minimum annual limit was $1.25 million for plans that started on or after September 23, 2011.
- The minimum annual limit was $2 million for plans that started on or after September 23, 2012.
- For plans issued or renewed on or after January 1, 2014, annual dollar limits on coverage of essential health benefits are not allowed.
So, if you have an individual health plan that was set up before January 2014, certain limits might be allowed because the plan is grandfathered. Check with your state Insurance Commissioner’s office. But starting in 2014, you may find that you can get comparable coverage without these limits in your state’s health insurance marketplace. The new law also:
- Does not allow insurance companies to deny coverage for pre-existing conditions (such as cancer) in children younger than age 19 as of September 2010. Pre-existing condition exclusions will not be allowed in plans for adults starting in 2014.
- Does not allow insurance plans to stop coverage when a person gets sick
- Created state-run or federally run Pre-Existing Condition Insurance Plans (PCIPs) in every state as a way to insure seriously ill people until 2014, when they could buy insurance through exchanges. People who are already in PCIPs can stay there until 2014, but they’re closed to new enrollees. .
- Makes coverage available across the US for patients who take part in clinical trials
- Enables young adults to stay on their parents’ health insurance until age 26.
Beginning in 2014, the law does several important things:
- It requires each state to set up a health insurance marketplace where people will be able to compare individual health plans (which includes many plans that cover families and dependents) and decide which one is best for them.
- It provides financial help to low- and middle-income people when health coverage through their employer is unaffordable, so that they can buy individual insurance in the health insurance marketplace. It’s important to know that affordability is calculated by the cost of an individual policy rather than a family policy.
- Requires that most Americans buy health insurance or pay a penalty along with their income taxes.
- It gives states the option to broaden access to Medicaid coverage to include everyone below a certain income level (133% percent of the federal poverty level; 133% is about $15,000 for one person and roughly $31,000 for a family of 4).
Health insurance marketplaces sell individual policies that can cover your family
By 2014, each state will have a health insurance marketplace (sometimes called a health insurance exchange) that offers consumers a one-stop shop online or through a toll-free phone number. There, they can compare health insurance plans by benefits, quality, and price. Information about prices and what a plan covers will be written in simple terms that are easy for people to understand. A person will be able to enroll in their chosen marketplace plan online, by phone, by mail, or in person. Read more about children and the marketplace under “The health care marketplace – finding individual plans for 2014 gets easier” in the section called “Private health plan coverage for children.”
People will not have to buy health insurance from the marketplace, but it will be the place to go if you’re looking for cost reductions and tax credits to help pay for insurance. Most employed people who get insurance through their employers are likely to keep it that way, so their situation may not change much.
If you are under 65 and can’t get health coverage through your employer, you may be able to buy a health plan that will cover your child through your state’s health insurance marketplace. Low- and middle-income people and families may get financial help (through the health insurance marketplace) so they can afford a plan sold on their state marketplace. People with health coverage through work whose individual health care premiums are too high compared to their income may also be able to buy coverage through the marketplace. If you have coverage through your job, but can’t get dependent coverage for your child, you may want to buy a child-only policy through the health insurance marketplace. Read more about children and the marketplace under “The health care marketplace – finding individual plans for 2014 gets easier” in the section called “Private health plan coverage for children.”
Starting in 2014, the health care law requires all health plans sold in a state marketplace to cover essential benefits, such as coverage for cancer screenings, treatment, and follow-up care. Each state’s marketplace will put the health plans into groups (platinum, gold, silver, or bronze) based on the level of coverage they offer and the cost of the plan.
The marketplace will automatically tell you if you qualify for financial help to buy a plan. It will also tell you if you qualify for Medicaid, a government program that offers health coverage to low-income people, or if your child qualifies for Children’s Health Insurance Program (CHIP). People who make up to $45,960 per year and families of 4 with a combined income of up to $94,200 a year should qualify for some help to purchase a health plan through the marketplace.
The question of affordability of employer-based coverage is based on the employee’s cost of the individual plan. This means that an employee whose job offers a reasonably-priced individual plan and a very expensive plan for dependent coverage may not qualify for any help or subsidies if they decide to purchase a family plan on the marketplace.
Still, low-income families may qualify for help in the individual coverage marketplace, or the child may qualify for low-income programs such as CHIP. For details on whether you qualify for marketplace help, and for how much, visit www.healthcare.gov, or find your state marketplace by calling 1-800-318-2596.
Choosing a plan
When choosing the plan that is right for you, it’s important to look at the benefits that the plan offers and the total amount you will be responsible for paying, including:
- Monthly premium – The monthly amount you pay the insurer for health coverage.
- Annual deductible – The amount you pay for health care in a calendar year before the plan begins to cover those costs.
- Co-pays – A flat dollar amount you pay for a covered health service, each time that you use that service.
- Co-insurance – The percentage of the total cost of the health service you are responsible for paying.
Enrollment in state health insurance marketplaces started October 1, 2013, and coverage begins January 1, 2014. Enrollment closes for the year March 31, 2014. You can enroll through www.Healthcare.gov/Marketplace. Help will be available in each state through trained “navigators” to answer questions and guide consumers.
Visit www.healthcare.gov to get more information about your state’s marketplace and how to enroll. If you don’t have internet access, you can call 1-800-318-2596 or see the “To learn more” section. Or you can watch for information about your state’s marketplace starting in October 2013.
To learn more, please read our brochure called The Health Care Law: How It Can Help People With Cancer and Their Families. You can also get up-to-date information online from the US Department of Health & Human Services at www.healthcare.gov.
Medicaid Under the ACA
Beginning in 2014, the health care law gives states the choice to cover more low-income people through Medicaid. States that take this option (see the Kaiser Family Foundation website at www.kff.org for updates) will extend Medicaid coverage to everyone earning up to a certain amount, regardless of whether they’ve ever qualified for coverage before. These “newly eligible” Medicaid beneficiaries, including children, will be covered for essential health benefits to prevent and treat serious diseases such as cancer.
The law also ensures that anyone can learn whether they are eligible for Medicaid through their state’s health insurance marketplace. The marketplace is a website where people can look for health coverage on their own. (See the section above called “Health insurance marketplaces” and the “Medicaid” section under “Government-funded health plans” below.)
Low-income people in states that chose not to expand their Medicaid coverage may find that they still don’t qualify for Medicaid. Many of these people also are not eligible for help paying for health insurance in the health insurance marketplace.
Avoiding identity theft and scams in the guise of health insurance
Scammers are already using the ACA to try to get your personal information for identity theft, or to sell you fake insurance. Some even call and pose as government workers looking to “update” your information, asking for your date of birth, Social Security number, or bank account numbers. Do not give this information over the phone until you can be absolutely sure who the call came from. If you get a scammer call, notify the FTC online at www.ftccomplaintassistant.gov/ or call 1-877-FTC-HELP (1-877-382-4357). Also see “Fake health insurance” in the “Private health plan coverage for children” section.
Last Medical Review: 10/07/2013
Last Revised: 10/07/2013