- Covering the costs of cancer treatment
- Private health insurance options
- Types of private health plans, and what you must pay
- Other things to know about health insurance
- Getting answers to insurance-related questions
- Keeping records of insurance and medical care costs
- When you have problems paying a medical bill
- Handling a health insurance claim denial
- Keeping employer-sponsored health insurance coverage
- COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986)
- The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- The Family and Medical Leave Act of 1993
- The Americans With Disabilities Act of 1990
- Government-funded health plans
- Who regulates insurance plans?
- Health insurance options for the uninsured
- Financial issues: Getting help with living expenses
- Getting money from life insurance policies
- Other sources of financial help
- Disability benefits
- To learn more
Other things to know about health insurance
Fake health insurance and other deceptions
There have always been people who look to profit from the needs and hardships of others. Now they’re exploiting the health care law in many different ways. They may advertise on hand-lettered signs, post ads on Internet sites, or go door-to-door. They may be completely fly-by-night or they may have a legitimate-sounding 800 number. There are 3 basic approaches:
A common tactic is to offer a stripped-down insurance policy that doesn’t meet the law’s requirements for covering major illness. These policies are cheap because they make you pay for most of your own care. By the time you find out you have a serious illness it may be too late to get real coverage.
Another way is to offer a medical discount card that gives you minor discounts but leaves the big payments up to you. Sellers might call this “coverage” or “protection,” but it’s neither. Discount cards can be helpful, but they don’t take the place of health insurance.
The third offers completely fake health insurance. The seller takes your money and gives you a piece of paper. They may promise lower rates if you buy now. The seller might say that they’re “required” to offer this great, low-cost coverage by the Affordable Care Act. Sometimes scammers say that it’s government-sponsored insurance or that they work for the government. Or they’ll use a well-known insurance company’s name, even though they don’t work for the company.
Some fraudsters have gone to great lengths to create websites that mimic official marketplace websites. These sites are designed to fool people into thinking they are on an official marketplace site. They may offer anything from fake health insurance to a policy that doesn’t cover serious illnesses. Be sure you are on healthcare.gov, your state’s official website, or a site they refer you to before entering any personal information.
Identity theft scams
A final way that scammers may exploit you is by trying to get your personal and financial information for identity theft. Some might 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. According to the Federal Trade Commission, federal government employees never call you to update your insurance data. If you get such a call, do not provide any of your personal information. Instead, contact your plan directly to see if they called. You can get your plan’s toll-free phone number by going to www.healthcare.gov or calling 1-800-318-2596. If you get a call from a scammer, notify the FTC online at www.ftccomplaintassistant.gov or call 1-877-FTC-HELP (1-877-382-4357).
How to spot scammers
The best way to avoid scammers is to shop for your insurance at www.healthcare.gov or by calling 1-800-318-2596. Scammers may still call, but your insurance choices can be safely made on the marketplace without regard to the scammers’ efforts.
If you want to hear from non-marketplace plans, watch out for aggressive sales people, very low premiums and a push for you to sign up today. They may try to evade your questions, and often don’t have the full policy details in writing. Some offer you coverage only if you join an association, union, or other group. You may not get an insurance card and policy for some time after you sign up, if ever. And when you file a claim, there’s no response or a very slow response; when you call they explain it’s a glitch or processing error – if they answer at all. Here are some tips to help you protect yourself.
- Don’t give them money, but especially don’t give them credit card information, birth date, Social Security number, or bank account numbers unless you are sure exactly who they are and what you’re getting.
- Ask for the Summary of Benefits and read it carefully (see “How to manage your health insurance” in this section). If you’re in doubt, read the full policy or have someone read it for you.
- Check out any association you have to join to get insurance – go online, be sure they have a street address, and find out if they have any legitimate activity besides selling insurance.
- Call your state insurance department to be sure the plan is licensed in your state. Also ask if the plan has had complaints made against it. (See the “To learn more” section to find your state insurance department.)
- Finally, check with your doctor and pharmacist to be sure they accept the plan.
Treating and managing most cancers costs a lot of money. Some insurance plans offer supplemental coverage called “catastrophic” coverage with high deductibles and fairly low premiums.
Catastrophic illness insurance is sometimes called a hospital-only or short-term plan. The plans often won’t cover doctor visits, medicines, or routine care, but kick in when you are hospitalized and have very high expenses. Depending on the policy, expect to pay a few thousand dollars for the deductible alone and some percentage of co-insurance on the rest of the bill plus the total cost for any items and services not covered by the plan.
Even though they can be called “hospital-only,” the plans won’t necessarily cover all or even most of your hospital bill. It is important to understand exactly what the plan will cover and not rely on catastrophic plan for your primary coverage. These plans will not provide comprehensive coverage to treat a disease such as cancer and do not meet the requirement of the health care law to have insurance. If this is your only form of coverage, you will likely still face a penalty at tax time unless you’re exempted from the requirement to buy health insurance.
Catastrophic coverage plans may be offered in the state health care marketplaces for people with low incomes or who are exempt from having to get standard health coverage. The marketplace plans have some advantages over catastrophic coverage plans not sold in the marketplaces, in that they cover 3 annual doctor visits and preventive benefits. People with this exemption don’t have to pay a penalty at tax time. But a person who requests an exemption from buying a regular health plan can’t get help paying the premiums for catastrophic coverage, even if their income is very low.
Health Savings Accounts
If you have enrolled or plan to enroll in an insurance plan with a high deductible, you may be able to set up a Health Savings Account (HSA). You don’t have to pay federal income taxes on the contributions you make to the HSA if the money is used to pay for qualified medical expenses. If you use it for anything else, you will be required to pay the tax and a penalty.
Note that an HSA is different from a Flexible Spending Account (FSA); for instance, you can have an FSA even if you don’t have a high-deductible health plan. FSA funds are set up to be used for both medical and child care expenses. But the FSA money you don’t use goes away at the end of each year, while the HSA money is yours until you take it out. For more information about setting up an HSA contact your employer, bank, or credit union.
Pre-existing condition exclusions
A pre-existing condition is a health issue that you had before you joined your health plan. Before the new health care law went into effect, health plans could impose a pre-existing condition exclusion period on patients, meaning that the patient would have to wait a certain amount of time before the plan would pay any health care costs related to the pre-existing medical problem. The wait could be as long as a year for employer plans, and some individual plans refused to cover certain pre-existing conditions such as cancer at all.
The health law prohibits most health plans from imposing pre-existing condition exclusion periods, or from refusing to cover people with a pre-existing condition at all. However, some health plans, including some “grandfathered” plans that were in existence when the law was signed in March 2010, can still have exclusion periods for pre-existing conditions. Employers can sign up new employees for grandfathered plans if the employer has had the plan since 2010, so employees may need to ask if their plan is grandfathered.
“Grandfathered” employer plans: Federal law has long prevented employers from applying exclusion periods for a pre-existing condition in some situations, a policy that still applies to grandfathered employer plans. You may be able to avoid the exclusion period in a grandfathered plan if you have had health insurance with a previous employer and have not been without health insurance coverage for more than 63 days. Some states require employer plans to cover pre-existing conditions even for people who were without insurance for more than 63 days. You can call the US Department of Labor at 1-866-444-3272 to find out more about your specific situation. (See the section called “The Health Insurance Portability and Accountability Act of 1996” for more information.)
“Grandfathered” individual policies: Grandfathered policies in the individual market can still impose exclusion periods on people with pre-existing conditions. If you have a grandfathered individual plan, the pre-existing condition exclusion period could still be many years or even unlimited. Such plans can also continue to impose an elimination rider that keep that disease, body part, or body system from ever being covered by that policy. It’s important to know these things before you sign up. (See “High-risk pools” in the section “Health insurance options for the uninsured.”)
“Grandfathered” plans going away: The health care law defines grandfathered plans as those that were being sold when the law began to go into effect in March 2010 and that haven’t made significant changes to the coverage they offer or the prices they charge. Because health plans frequently change their coverage and/or price from year to year, many plans lose their grandfathered status over time. The total number of grandfathered plans is shrinking, and eventually there will be few, if any, grandfathered plans left. If you have had your individual insurance plan or your employer has had the same plan since March of 2010, it’s important to find out if it’s a grandfathered plan.
Hospital indemnity policies and other supplemental insurance
Hospital indemnity policies, sometimes called supplemental medical policies, pay a fixed amount for each day a person is in the hospital. There may be a limit on the total number of days it will pay for in a calendar year, or a cap on the total number of days it will ever pay. The money received from this type of policy can be used however the insured wishes. It’s often used for medical costs not paid by the insurance company, or the other expenses that families face when one member is ill.
These supplemental plans don’t provide comprehensive coverage to treat a disease such as cancer and don’t meet the requirement of the health care law to have insurance. So, if this is your only form of coverage, you will likely still face a penalty at tax time. You could also be liable for significant out-of-pocket costs if you have a serious illness.
Critical-illness policies: There are other types of policies that offer extra money in case a person gets one certain kind of health problem such as cancer, stroke, or an accident. You can’t buy these critical-illness policies after you are diagnosed, and there are often conditions and waiting periods. The limitations on these types of policies mean that for many people with health insurance, they are not worth the expense.
Long-term-care insurance: This is not health insurance, but includes long-term medical and non-medical care given to people who need help performing basics like eating, dressing, walking, toileting, or bathing. Long-term services might be given at home, or in community, assisted living, or nursing homes. Unpaid family members often provide this kind of care in the home.
Terms of long-term-care insurance policies vary. For instance, most policies don’t start paying until more than 90 days of such care are needed, but some wait up to a year to start covering it. Home care may be covered separately or not covered at all in some policies. Long-term-care insurance can be very expensive. Medicare and most health insurance plans don’t pay for long-term care.
National law prohibits discrimination based on genetic testing or test results
The Genetic Information Nondiscrimination Act (GINA) does not allow health insurers to turn down individuals or charge higher premiums for health insurance based on genetic information or the use of genetic services, such as genetic counseling. GINA defines genetic information as any of these:
- A person’s own genetic tests
- The genetic tests of family members
- One or more family members with a genetic disease or disorder
GINA bars group health plans, individual plans, and Medicare supplemental plans from using genetic information to limit enrollment or change premiums. It also forbids these insurers to request or require genetic tests. GINA applies to all health insurance plans (including federally regulated plans, state-regulated plans, and private individual plans).
The law also forbids discrimination by employers based on genetic test results or genetic information. GINA states that employers must not discriminate on the basis of genetic information (no matter how they got the information) in hiring, firing, layoffs, pay, or other personnel actions such as promotions, classifications, or assignments.
How to manage your health insurance
- DO NOT let your health insurance expire.
- If you are changing insurance plans, don’t let one policy lapse until the new one goes into effect – this includes when you are switching to Medicare.
- Pay your health insurance premiums and other costs in full and on time. New insurance can be hard to get--you don’t get a special enrollment period to buy marketplace insurance if you lost coverage because you didn’t pay premiums.
- Know the details of your individual insurance plan and its coverage. Ask for a Summary of Benefits (SPB), an easy-to-understand description of a plan’s benefits and the costs you will have to pay. If you think you might need more coverage than a plan offers, ask your insurance carrier if it’s available.
- When possible, call the insurer to make sure that any planned medical service (such as surgery, procedures, or treatments) does not require prior authorization.
- If a bill looks odd or wrong, make sure to call or email your insurer to avoid being mistakenly charged more than you should.
- Submit claims for all medical expenses, even when you’re not sure if they’re covered.
- Keep accurate and complete records of claims submitted, pending (waiting), and paid.
- Keep copies of all paperwork related to your claims, such as letters of medical necessity, explanations of benefits (EOBs), bills, receipts, requests for sick leave or family medical leave (FMLA), and correspondence with insurance companies.
- Get a caseworker, a hospital financial counselor, or a social worker to help you if your finances are limited. Often, companies or hospitals can work with you to make special payment arrangements if you let them know about your situation.
- Send in your bills for reimbursement as you get them. If you become overwhelmed with bills or tracking your medical expenses, get help from trusted family and friends. Contact local support organizations, such as your American Cancer Society or your state’s government agencies, for extra help.
Last Medical Review: 02/16/2015
Last Revised: 02/16/2015