- Children Diagnosed With Cancer: Financial and Insurance Issues
- Covering the costs of cancer treatment
- Private health insurance options
- Types of private health plans 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
- Government-funded health plans
- Who regulates insurance plans?
- Options for uninsured children
- 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
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, especially for people with serious diseases such as 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 health care law, please read our brochure called The Health Care Law: How It Can Help People With Cancer and Their Families. You can also call us anytime at 1-800-227-2345 for the most up-to-date information and for answers to health insurance questions.
Group health plans
Group health plans cover a group of people (usually employees of the same company) and often their dependents. Some employers pay part of employee health care premiums, which are the monthly payments required to continue coverage.
Many people get health insurance coverage for their dependent children by listing them as dependents on their own employee plan, so that they’re covered by the group plan offered by their employers. Under the health care law, employers with 50 or more full-time workers must offer health insurance as of January 1, 2015 or pay a penalty. Employers with fewer than 50 full-time workers are not required to offer health insurance.
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 through their state’s health insurance 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.)
Most people who get health insurance for their families through their jobs can 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.”
Grandfathered group health plans
Grandfathered group health plans are older plans that don’t have to meet all the requirements of the new law, even if your employer is still enrolling new people in them. If you’re 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 find out when your plan started and whether it’s grandfathered.
Individual health plans
Insurance companies sell individual health plans directly to a person, not through an employer.. Even though it’s called an individual plan, many individual plans also cover family members or dependents. The name refers to how you buy it rather than how many people it covers.
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
- Prohibits insurance plans from charging sick people – including those with cancer – more for coverage than healthy people
- Requires that most individual health plans cover 10 categories of essential health benefits
- Prohibits annual and lifetime dollar limits on the amount the plan will pay 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 for people with low or moderate-incomes to buy health insurance when health coverage through their employer is unavailable or unaffordable. (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, exceptions, and cancellations
Individual health plans that don’t meet the requirements of the new law, including those listed above, can continue to be sold if they existed before the law was signed in March 2010 and have stayed essentially the same since then. (These are called “grandfathered” plans.)
Health plans that have made substantial changes to their coverage since March 2010, or have been created since then, must adapt to the law’s requirements, with some exceptions. One important exception applies to health plans that aren’t technically grandfathered but still don’t meet the law’s requirements for coverage. These non-grandfathered plans, which apply to individual and small-group plans, may continue to be sold through Oct. 1, 2016.
Insurance companies can cancel a health plan for several reasons. However, plan cancellations have received more attention than usual since the health care law went into effect. People across the country have received notices from insurers that their individual plan has been or will be canceled. State insurance commissioners were given the option to allow health plans scheduled for cancellation at the end of 2013 to be extended. In states where insurance commissioners approved, insurers were given the option to keep selling these plans to current policyholders. Keep in mind that these plans can still discriminate based on health status and/or history by charging more or denying coverage, because they aren’t 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 can’t continue to sell coverage beyond October 1, 2016.
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 in each state. All plans sold in the marketplaces meet the requirements of the Affordable Care Act. Costs are controlled, and patients get clear information about the coverage offered. Individual health plans are still 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 in buying 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. 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
If your child is eligible for a marketplace plan, there will be a open enrollment period beginning November 15, 2014 and ending February 15, 2015. This is a chance to enroll in a new plan or find a different one. People with a life-changing event such as job loss, insurance loss, divorce, moving out of their plan’s service area, or the birth of a child can have a special enrollment period even after open enrollment is over. 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. The Spanish version can be found at www.CuidadoDeSalud.gov.
- Call the Health Insurance Marketplace at 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 or www.CuidadoDeSalud.gov.
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 don’t have to buy health insurance from the marketplace, but it’s 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 help 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: 11/13/2014
Last Revised: 01/08/2015