Health Insurance and Financial Assistance for the Cancer Patient

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TOPICS

Government-funded health plans

Medicare

Medicare is a federal health insurance program, for people age 65 and older and those under 65 with certain disabilities. To qualify for Medicare you must be a US citizen or qualified legal immigrant who meets certain criteria. Young people with cancer may get Medicare benefits after collecting Social Security benefits for 2 years under the Supplemental Security Income program.

You can get more information from the Social Security Administration (check the blue pages of your phone book or the “To learn more” section in this document), or by talking with your cancer care team social worker.

Medicare is offered to people who meet one or more of these requirements:

  • Age 65 or older
  • Have been permanently disabled and are getting disability benefits from Social Security (after a 2 year waiting period)
  • Have permanent kidney failure treated with dialysis or a transplant
  • There are two types of Medicare plans:
  • Original (traditional) Medicare
  • OR

  • Medicare Advantage Plans – which are offered by private insurers.

Medicare has 4 parts

Part A pays for hospital care, home health care, hospice care, and care in Medicare-certified nursing facilities. For most people, there’s no monthly premium, but you pay a yearly deductible before Medicare pays anything. After that’s paid, Medicare pays its share, and you pay your share (your co-insurance or co-pay) for covered services and supplies. You can go to any doctor or supplier that accepts Medicare and is accepting new Medicare patients, or to any hospital or other facility. You may have a Medigap policy or other supplemental coverage that may pay deductibles, co-insurance, or other costs that aren’t covered by Medicare Part A. (See below, “Private insurance coverage that can be added to Medicare.”)

Part B covers diagnostic studies, doctors’ services, durable medical equipment used at home, some home care, and ambulance transportation. Part B is optional, and there’s a monthly premium which is based on your income. Each year, before Medicare pays anything, you must pay your own medical expenses to equal the deductible, based on Medicare’s approved “reasonable charge,” not on the provider’s actual charge. And you must still pay co-insurance or aco-pay on the rest of the covered charges for that year.

Part C is actually a combination of Parts A and B but it’s only known as Part C when it’s provided by private insurers. It’s called Medicare Advantage. The private insurance companies must be approved by Medicare, and must provide all hospital and medical benefits covered by Medicare. The private insurers in Medicare Advantage charge a monthly premium, and some include the Part D prescription drug coverage (see “Part D” next paragraph), as well as extra benefits like vision, hearing, and dental coverage. Part C is not available everywhere. Medicare Advantage plans can be PPOs, HMOs, or fee-for-service plans. (See the section “Types of health plans” for more on these different plans.) There’s also a Part C Medicare Special Needs plan, which is designed for people with long-term health problems. These plans must include Parts A, B, and D coverage.

Part D is optional. It helps pay for prescription drugs that are usually bought at a retail pharmacy. You can enroll in Part D through a Medicare Advantage plan or, if you are in traditional Medicare, you can buy drug coverage. You pay a monthly premium, which varies by plan, and a yearly deductible. You will pay a higher premium if you didn’t sign up for Part D when you first became eligible, unless your drugs were covered by another plan (“creditable” prescription drug coverage). You will also pay a part of the cost of your prescriptions through co-pays or co-insurance. Costs vary based on which drug plan you choose. Some plans may offer more coverage and a wider choice of drugs for a higher monthly cost. If you have limited income and resources, you may qualify for extra help, so that you don’t have to pay a premium or deductible. You can apply or get more information about the extra help by contacting the Social Security Administration (see “To learn more” for contact information). You can find out more about Medicare Part D and how it applies to people with cancer in our document Medicare Part D: Things People With Cancer May Want to Know.

The new health care law makes some important changes to Medicare. For example, it closed the “donut hole” in Part D that forced some seniors to pay high costs for prescription drugs. It makes proven cancer screenings, such as mammograms and colonoscopies, and other preventive care available at no cost to people in Medicare if it is provided based on accepted guidelines. And it makes sure that Medicare covers a yearly check-up to discuss disease prevention and ways to stay healthy. For more on this, see our document called Medicare Part D: Things People With Cancer May Want to Know.

Medicare provides basic health coverage, but it won’t pay all of your medical expenses. For example, it may cover the costs of prostheses (substitute body parts) or bras, but the number covered per year can vary from state to state. Medicare also limits the number of ostomy supply items it covers each month.

A lot of confusing information and rumors about how Medicare benefits change (or don’t change) under the new health care law have been going around. If you have Medicare questions, call 1-800-633-4227 or contact your local Social Security office. You can also go online to www.medicare.gov to find the annual Medicare handbook, or get personalized Medicare counseling at no cost to you through the State Health Insurance Assistance Program (SHIP). Contact information for each state SHIP is included in the back of the printed Medicare handbook or online at www.medicare.gov.

Private insurance coverage that can be added to Medicare (Medicare Supplement Insurance or Medigap)

If you are enrolled in standard Medicare, you may be able to add more coverage with a Medicare Supplement Insurance policy (commonly called Medigap). There are 10 standard Medigap policies. Each offers a different combination of benefits and is offered in all 50 states, but the plans may not be the same in all states. The plans are identified by letters A through J. It’s important to compare Medigap policies because premiums and other costs can vary, and some of the plans expect you to use only certain doctors or hospitals.

Medicaid

Medicaid is state and federal government program that covers much of the cost of medical care for people with income below a certain level. These levels can vary from state to state. Not all health providers accept Medicaid.

In past years, Medicaid covered specific groups of people, including:

  • Low-income families with children
  • Supplemental Security Income (SSI) recipients
  • Children under age 6 from low-income families may be eligible in some states (even if other family members are not)
  • Pregnant women whose income is below the family poverty level
  • Infants born to Medicaid-eligible pregnant women
  • Low-income women with breast or cervical cancer who were diagnosed through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

Several states still limit Medicaid to the above groups of people, but the health care law now gives states the choice to cover more low-income people through Medicaid. States that take this option (see the Kaiser Family Foundation website for updates) have extended Medicaid coverage to everyone earning up to a certain amount, whether or not they fall into one of the specific categories listed above. The law offers federal money to pay all of a state’s costs to increase Medicaid coverage at the start, with the federal share slowly going down to 90%.

In the states that have decided not to cover more people through Medicaid, many low-income people still won’t qualify for Medicaid. Some very low-income people who don’t qualify in these states also won’t qualify for help paying for a private insurance plan in the marketplace. For details on whether you qualify and for how much, visit www.healthcare.gov, or find your state marketplace by calling 1-800-318-2596. States can decide at any time to extend Medicaid coverage as allowed under the health law. If you live in a state that has broadened its Medicaid coverage, it’s a good idea to re-apply in 2014, even if you’ve been turned down before.

The “newly eligible” Medicaid beneficiaries are those who will benefit from their state’s decision to cover more people under the program. They are covered for the law’s 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. You also can get information on the marketplace by phone (see “Where to get private coverage: the health insurance marketplaces” in the “Private health plans” section).

Medicare plus Medicaid: People on Medicare who also have a low income and limited resources may get help paying for their out-of-pocket medical expenses from their state Medicaid program. For more information, contact your state Medicaid office (see the “To learn more” section).

State-sponsored children’s health insurance programs

There’s a special state and federal partnership that pays for medical services for children called the Children’s Health Insurance Program (CHIP). CHIP offers some type of low-cost health insurance to uninsured children and pregnant women in families with incomes too high to qualify for state Medicaid programs, but too low to pay for private coverage.

Within federal guidelines, each state sets up its own CHIP program, including eligibility guidelines, benefits offered, and cost. The program covers doctor visits, medicines, hospitalizations, dental care, eye care, and medical equipment. It’s funded by state tax dollars. People enrolled in Medicaid usually are not eligible for state sponsored health insurance programs.

To find out more about CHIP, call 1-877-543-7669. You can also go to the CHIP website, www.insurekidsnow.gov, to learn more about the program and find your state’s CHIP.

Veterans’ and military benefits

Veterans: If you have ever been on active duty in the military, you might qualify for Veterans Administration (VA) health benefits. The VA looks at how long you served, the type of discharge you received, disability, income, availability of VA services in your area, and other factors to decide if you are eligible. Veterans’ benefits change often, and the number of veterans’ medical facilities has been declining in recent years. See the “To learn more” section to learn how to contact the Department of Veterans Affairs to get the latest information.

Active duty, reservists, retirees, survivors, and family: TRICARE is the Department of Defense’s health insurance program for those in the military, as well as some family members, survivors, and retirees. It offers a number of different plan options to cover people in the US and overseas, and includes family plans as well as plans for certain reservists. Pharmacy plans, dental plans, and other special services are available for some beneficiaries. If you were or are married to a veteran who retired from the military you may be eligible for Tricare.

Each TRICARE plan has its own limits and requirements. Choose your plan carefully and know how it works. Contact TRICARE for complete and current information on TRICARE benefits for those who have been in the military and their families, including eligibility, plan details, and cost, as well as how to find providers in your area. You can find this information online, including the number to call in your area, at www.tricare.mil.

Widows or widowers, and spouses or children of military members with service-related disabilities: Another program called Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available to certain spouses or widows(ers) and their children who are not eligible for TRICARE. CHAMPVA can cover the spouse or widow(er) and the children of a veteran who:

  • Is permanently and totally disabled due to a service-connected disability as determined by a VA regional office
  • Was rated permanently and totally disabled due to a service-connected condition at the time of death
  • Died from a service-connected disability
  • Died in the line of duty and the family members are not eligible for TRICARE benefits

CHAMPVA is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. The program is administered by the VA Health Administration Center. You can find out more about CHAMPVA, including things like eligibility, benefits, finding a provider, and filing claims by calling 1-800-733-8387, or visiting their website, www.va.gov/hac (select CHAMPVA under “Special Programs”).

Activated reservists and their employee health benefits: Members of the military reserve units who are called up for active duty from private employment have specific rights about the health care coverage they get from their employers. They are allowed to pay the full cost of insurance, very much like COBRA, during their time away. When they return to work, their coverage must be reinstated without any waiting period. See the “To learn more” section for US Department of Labor contact information.

Breast and cervical cancer screening and treatment for low-income women

Medically underserved women can get tested for breast cancer for free or at very little cost through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This program provides breast and cervical cancer early detection testing for women who are uninsured, or in some cases under-insured. Every state offers the program, and the Centers for Disease Control and Prevention (CDC) helps support the program.

Although the NBCCEDP can help women find cancer early, uninsured women still need help getting treatment. The Breast and Cervical Cancer Prevention and Treatment Act provides money to pay for breast and cervical cancer treatment for certain uninsured women who are under age 65. As in the NBCCEDP, each state must adopt the program to get the matching federal funds. Even though the money is channeled through each state’s Medicaid program, it helps women who would not otherwise be eligible for Medicaid.

This program will continue to be necessary even with the new health care law, especially in states that choose not to cover more people through Medicaid. The program will also serve as a critical safety net in states that choose to increase access to Medicaid coverage.

Some states are considering phasing out their NBCCEDP programs, so it’s important to check on the status of the program in your state. Information on the NBCCEDP can be found on the CDC website at www.cdc.gov/cancer/nbccedp/index.htm, or you can call the CDC at 1-800-232-4636 to learn more.


Last Medical Review: 12/31/2013
Last Revised: 12/31/2013