Children Diagnosed With Cancer: Financial and Insurance Issues

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Private health insurance options

The new health care law known as the Affordable Care Act (ACA) is intended to make private health insurance more affordable for people with cancer in the family. The law also ensures that most insurance plans cover the health care needed by cancer patients and survivors. This section looks at the law’s impact on different types of private health insurance.

For an overview of the new law, please read our brochure called The Health Care Law: How It Helps People With Cancer and Their Families. You can also call us anytime at 1-800-227-2345 for the most up-to-date information.

Group health plans

Many people get health insurance coverage for their dependent children by listing them as beneficiaries on their own employee plan, so that they are covered by insurance through a group plan offered by their employers. Under the new health care law employers with more than 50 full-time workers must offer health insurance or pay a penalty. Employees whose health insurance is too expensive (more than 9.5% of their household income for just the employee’s coverage) can look into buying an individual plan in their state’s marketplace. Some of these people will qualify for financial help to pay for a marketplace insurance plan. (See “Where to get private individual coverage: the health insurance marketplace” in this section.)

Group health plans cover a group of people, usually employees of the same company, and many plans cover their dependents, including children. Generally, employers must offer health coverage to full-time employees. Some employers pay part of employee health care premiums, which are the monthly payments for coverage.

Most people who get health insurance through their jobs will continue to do so under the new health care law. If your employer charges less than 9.5% of your household income for single coverage (insurance that covers just you), it’s likely you won’t qualify for financial help to buy an individual plan to cover you and your family in the marketplace.

If you find it hard to afford the amount your employer charges for a plan that covers your children, you may want to contact your state marketplace to find out if your children might get coverage there at a lower cost (see “Individual health plans” below). You can also find out if your children qualify for any special programs such as CHIP or Medicaid. For more on these programs, see “State-sponsored children’s health insurance programs (CHIP)” and “What is Medicaid” in the section called “Government-funded health plans.”

Some group plans are grandfathered

If you are still in a group plan that your employer had in March 2010, certain limits on health insurance might be allowed because the plan is “grandfathered.” Check with your insurance administrator at work or look at your Summary of Plan Benefits to learn when your plan started and find out if it’s grandfathered. Grandfathered group plans don’t have to meet all the requirements of the new law, even if your employer is still enrolling new people in them.

Individual health plans

Individual health plans are sold by insurance companies directly to a person, not through an employer. Some individual plans also cover family members or dependents. It’s important to know that even though it’s called an individual plan, it can still cover your family. The name refers to how you buy it rather than how many people it covers.

For many years, individual health plans could vary a lot by the types of health care services they covered, the amount of care they would pay for, how much they charged, and the types of people they covered. For example, insurance companies could look at your personal and family health history, and require physical exams or lab tests before deciding whether to insure you or your family. Based on the results, they could decide not to offer you a health plan, or they could charge you higher monthly premiums than they did to younger, healthier people. They could require people who were sick or injured to pay more for their care or turn them down for coverage altogether. They also offered different levels of coverage, with many plans not covering the care needed by someone with a serious illness like cancer.

Parts of the new health care law call for major changes in individual health plans. The law is designed to improve the coverage these plans offer and make these plans more affordable for people with cancer or other serious illnesses. For instance, the law:

  • Requires health plans to cover children and adults with a pre-existing condition such as cancer (Pre-existing conditions are illnesses that a person has before getting health insurance.)
  • Prohibits insurance plans from canceling coverage if the patient gets sick
  • Requires that most individual health plans cover 10 categories of essential health benefits
  • Prohibits annual and lifetime dollar limits on the amount of a patient’s care the plan will pay for, in plans that started on or after January of 2014
  • Requires insurers to provide current policyholders and people shopping for coverage with a short and simple summary of their coverage
  • Allows young adults to stay on their parents’ health insurance until age 26
  • Makes sure that patients who take part in clinical trials are covered for their other health needs
  • Provides financial help to low- and middle-income people when health coverage through their employer is unavailable or 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 most Americans, even children, to have health insurance unless the family income is very low or there are special exemptions for each family member. (If a child is uninsured and doesn’t have an exemption, parents pay a penalty with their income taxes.)

Grandfathered individual health plans and cancellations

Individual health plans that do not meet the requirements of the new law, including those listed above, can continue only if they existed before the law was signed in March 2010. (These are called “grandfathered” plans.) If you bought a new individual policy in or after January 2014, it must meet all the new law’s requirements. If you bought one between those dates, it must meet most of the new health care law requirements but there are a few limits it might have.

Unless a health plan stayed essentially the same after March of 2010 and became grandfathered, it must adapt to the law or be discontinued. This is one reason that many people across the country have received notices from insurers that their individual plan has been or will be canceled. State insurance commissioners now have the option of allowing health plans that were slated to be cancelled at the end of 2013 to be extended for another year. In states where insurance commissioners approve, insurers will have the option to continue these plans for current policyholders. Keep in mind that these plans can still discriminate based on health status or history by charging more or denying coverage, because they are not required to comply with all of the patient protections included in the health care law. If your child is covered under one of these plans, you may want to look at how well it meets your child’s needs before you decide whether to keep it. Also be aware that these plans cannot continue to offer coverage beyond the end of 2015.

People facing the cancelation of their family coverage may have other options from their insurer, or they can look at plans sold in one of the new marketplaces.

Where to get private individual coverage: the health insurance marketplaces

You can buy health insurance coverage (online, by phone, by mail, or in person) through the health insurance marketplaces. All plans sold in the marketplaces must meet the requirements of the new law that make sure plans cover certain benefits. Costs are controlled, and patients get clear information about the coverage offered. Individual health plans can still be sold outside the marketplaces, but the financial help that the law provides to help low- and middle-income families pay for coverage is only available with marketplace plans.

If you are under 65 and can’t get your child covered through your employer, you may be able to buy a health plan for your child through your state’s health insurance marketplace. If you can’t get coverage for yourself at work, there are plans on the marketplace that cover entire families. Low- and middle-income people and families may be able to get financial help through the marketplace to help them afford a plan. People with health coverage through work whose health care premiums are too high compared to their income may also be able to buy coverage through the marketplace.

The health care law requires that all health plans sold in a marketplace cover essential health benefits, such as cancer screenings, treatment, and follow-up care. Each state’s marketplace puts the health plans into groups, or “tiers,” based on the level of coverage they offer and their cost to consumers. The highest tier is platinum, followed by gold, silver, and bronze. The platinum level is more costly up front, but tends to pay higher percentages of your medical costs and has lower deductibles. The bronze level costs less, but the out-of-pocket costs are higher in case of an illness.

After you give your information, the marketplace will tell you if you qualify for financial help to buy a plan. Individuals 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 help buying a health plan through the marketplace. The marketplace will also tell you if your child qualifies for Children’s Health Insurance Program or for Medicaid. See “State-sponsored children’s health insurance programs (CHIP)” and “What is Medicaid” in the section “Government-funded health plans” for more on this. The law gives states the choice to enroll more people in Medicaid coverage than ever before, but not all states have decided to do so. For details on whether your child might qualify, visit www.healthcare.gov, or find your state marketplace by calling 1-800-318-2596.

Enrolling in a marketplace plan

Enrollment in the marketplaces for private, individual health plans began October 1, 2013. People who enrolled by Dec. 24 had coverage as of January 1, 2014. The first marketplace open enrollment period ends March 31, 2014. Another open enrollment period will begin in November 2014, though people with a life-changing event such as job loss, divorce, moving out of their plan’s service area, or the birth of a child can enroll in a marketplace plan at times outside of the open enrollment period. You have up to 60 days after the event to enroll in a marketplace plan. There are a few ways to enroll:

  • Visit www.healthcare.gov, the federal government’s official marketplace website. Whether your state offers the federally run marketplace or is operating its own marketplace, you’ll be directed to the right website through www.healthcare.gov.
  • Call the federal toll-free number, 1-800-318-2596, to enroll over the phone (TTY: 1-855-889-4325). Information about your state’s marketplace and the plans sold on it is offered 24 hours a day, 7 days a week in more than 150 languages.
  • Apply in person with the help of a trained counselor in your community. Find help in your area online at https://localhelp.healthcare.gov.
  • Complete a paper application and mail it in. You can download the paper application form and instructions from www.healthcare.gov.

When the state marketplaces opened in October 2013, some had technical problems that made it difficult to use their websites to enroll in a plan. Most of these problems have since been fixed. If you have problems with online enrollment for any reason, it might be best to choose one of the other options, such as phone, mail, and in-person enrollment.

Private individual plans that aren’t part of the marketplace

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 to cover you and your family. If you go to a private broker or some other non-marketplace source, you can’t qualify for financial assistance buying your plan. Be sure that the plan you buy meets the minimum essential coverage requirements, otherwise you could end up paying a penalty at tax time.


Last Medical Review: 01/14/2014
Last Revised: 01/14/2014