Health Insurance and Financial Assistance for the Cancer Patient

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TOPICS

Who regulates insurance plans?

It’s important to know who regulates a health plan if you have a problem that you can’t resolve directly with the plan. You have the option of talking to the government group that regulates the health plan to find out if they can offer more information or extra help.

  • Private group plans (or fully insured plans) purchased from insurance carriers by employers as a benefit for employees are usually overseen by the insurance commissioner or department of insurance in each state. You can find your state’s insurance department in the blue pages of your local phone book, or contact the National Association of Insurance Commissioners (see the “To learn more” section for contact information).
  • Self-funded plans (or self-insured plans) are health plans that employers or unions create just for their employees and their families. They are overseen by the US Department of Labor’s Employee Benefits Security Administration. (See the “To learn more” section for the website and phone number.) You may have to ask your employer if their health plan is fully insured or self-insured.
  • Individual plans sold through the health insurance marketplaces are regulated by a marketplace board in every state. This state board oversees the function of the marketplace and the plans sold within it.
  • Managed care plans are regulated by several state and federal agencies. Your state insurance commissioner or department of insurance can provide specific information about an individual plan.
  • Medigap policies (Medicare Supplement Insurance policies) are regulated by federal agencies, as well as some state laws. Contact the Centers for Medicare and Medicaid Services (CMS) and/or your state department of insurance for information.
  • Medicaid is a joint program that is controlled by your state health department and the federal Centers for Medicare and Medicaid Services.
  • Medicare is run by the federal Centers for Medicare and Medicaid Services.
  • TRICARE is overseen by the US Department of Defense.
  • The Veteran’s Health Care system (including CHAMPVA) is regulated by the US Department of Veteran’s Affairs.

Health insurance options for the uninsured

Shopping for insurance coverage

The health insurance law requires that most people have insurance coverage. If you don’t have health insurance, here are some things to think about when looking for coverage:

Look carefully at health insurance options at work

If you or your spouse is employed, sometimes it’s possible to add yourself, a spouse, or a child to a work health insurance policy during your employer’s open enrollment period. It can also be done at other times than the open enrollment period if you’ve had a major change in situation; for instance, if you’ve gotten married or legally separated, or one of you is laid off or lost health insurance for another reason. Check with your health insurance administrator at work about this. This person is usually in the human resources or employee benefits department.

Look closely when choosing among health insurance and managed care options. Sometimes there’s a chance to compare different types of coverage during open enrollment periods. (Open enrollment is the time employees can make changes in health insurance coverage. It usually happens once a year.)

Some workplace plans may be one of the grandfathered plans in which coverage is limited (with things like annual caps and pre-existing condition exclusions). Check before you sign up. (See “Grandfathered employer plans” in the section “Other things to know about health insurance.”)

If you get insurance through your job (or your spouse/partner’s job), you may want to keep the administrator’s phone number and email address handy. Group insurance is better for most people than individual insurance. But if you learn that your coverage will cost you more than 9.5% of your income, you may find a better deal in your state’s marketplace.

If you can’t get health insurance from an employer

  • Under the health care law, people looking for health coverage will be able to compare plans and select the best one for them on new online health insurance marketplaces in each state. Your state’s marketplace will collect information from you to find out if you qualify for Medicaid or financial help to pay for coverage. Each marketplace will have trained navigators to help you in the process. Visit www.healthcare.gov or www.CuidadoDeSalud.gov for information on your state.
  • You can also get marketplace information by phone. For the phone number of your state marketplace, visit www.healthcare.gov or www.CuidadoDeSalud.gov, or call 1-800-318-2596.
  • You can buy individual insurance outside the marketplace. Most plans will meet the requirements for sufficient coverage so that you avoid the penalty at tax time, but some won’t. Be sure to ask whether it meets the minimum requirement.
  • An independent insurance broker may be able to help you find a reasonable benefit package.
  • You or your spouse getting a job with a large company or a government agency is the surest way to get access to group insurance.
  • If you have been covered under your employer-sponsored plan for at least one day you should be able to keep your medical insurance through COBRA. Your employer must tell you, in writing, about your COBRA option. For more information, please see the section “COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986).”
  • Look into Medicare, which covers most people who are 65 or older, as well as those under 65 who are disabled and have been getting Social Security disability benefits for 2 years.
  • If you are in a low-income bracket or are unemployed, find out if you are eligible for state or local benefits such as Medicaid.
  • If you are employed, before you leave your job, find out if you can convert your group insurance to an individual plan. Some group plans have a clause that allows people to convert to individual plans, but premiums may be much higher. You usually must apply for these individual plans within 30 days of leaving a job. (This is different from COBRA, which allows you to stay with the group insurance but only for a limited time.)

In looking at insurance options, find out about differences in coverage. The health care law requires plans to provide a Summary of Benefits and Coverage (SBC). The SBC is an easy-to-understand document with details on the benefits and the costs you are responsible for. It includes specific disease examples to help compare which plan may be right for you. Look into these things:

  • Choice of doctors
  • Protection against cancellations
  • Premium costs
  • What the plan really covers, especially in the event of a catastrophic illness (a serious illness, like cancer, that can add up bills quickly)
  • How much the deductibles and co-pays will cost you

See the “Things to consider when shopping for health insurance” under “Private health insurance options” for more on this.

Be wary of ads or agents offering government-issued or low-cost health insurance. See “Fake health insurance” in the “Other things to know about health insurance” section for more on this.

If you think an insurance company has treated you unfairly, contact your state insurance commissioner. See the “To learn more” section to find your state insurance department.

Health insurance options for young adults

If you’re young and healthy, you may think you don’t have to worry about health insurance. But the new health law requires most Americans to have coverage. Even young adults have accidents and serious illnesses, and find themselves unexpectedly needing health care. There are health insurance options for this age group.

When choosing a plan, ask about coverage for common tests young people need, like preventive services, annual physicals, blood tests or x-rays. Be sure you’re not getting into a “grandfathered” plan that limits what is offered.

Here are some health insurance options for young adults:

Through your parent’s health coverage

The new health care law allows young adults to stay on their parents’ health plan up to the age of 26, if the plan has dependent or family coverage. This means that adult children can join or stay on a parent’s plan whether or not they are:

  • Married
  • Living with a parent
  • In school
  • Financially dependent on a parent (the young adult does not have to be listed as a dependent on the parent’s tax return)

The only exception is if the parent has an existing job-based plan and the young adult can get their own job-based coverage. If they can’t get their own job-based coverage, young adults who lose dependent coverage may qualify for COBRA even at age 26.

The insurance for young adults cannot cost any more than for dependent children under the age of 18.

Individual insurance

There are individual health insurance plans from private companies that are offered to young adults. The new health care law makes sure that insurers selling individual plans through the health insurance marketplace can no longer turn you down, charge more, or not offer certain benefits if you have a pre-existing health condition. The law now prevents insurers from denying coverage to people with pre-existing conditions. (See the section “Private Health Plans.”)

Visit www.healthcare.gov or www.CuidadoDeSalud.gov, or contact your State Department of Insurance for more information. You can find your state’s insurance department in the blue pages of your local phone book, or see the “To learn more” section to contact the National Association of Insurance Commissioners. If you qualify, you may also look at catastrophic health coverage from your state’s marketplace (see “Catastrophic coverage” in the section “Other things to know about health insurance”. Be sure you understand the coverage offered, including benefit limits, before you buy it.

Through your work or your spouse’s work

If your employer offers coverage, you generally can’t be turned away or charged more because of your health status. But employers can refuse or restrict coverage for other reasons (such as part-time employment), as long as these reasons are not related to your health and are applied to all employees.

Student health insurance programs

Some colleges or universities may offer reduced-cost student health insurance plans. These plans used to limit the amount of coverage they would pay for in a given year, but as of 2014, dollar limits are not allowed under the new health care law. If student plans are self-funded or offered by a student association, the rules may be different. Because of this, students need to be sure what they are buying. It’s also important to understand important coverage details, including how long you are covered and whether you must be attending classes to be covered. Sometimes a serious illness can keep you from going to class, and that’s when you need insurance.

One advantage of college plans is that they’re often integrated to cover any charges from Student Health Services, which may provide basic health care on campus. Keep in mind that many colleges and universities even offer counseling centers where students can get short-term therapy at no cost or for low cost co-pays at each visit. But Student Health Services, while good for minor illnesses, wouldn’t likely be very helpful for a person with a serious illness such as cancer.

State high-risk pools

State high-risk pools: Before the new health care law went into effect, people with a serious illness like cancer who didn’t have insurance through their job could look into a high-risk pool in most states. High-risk pools are private, self-funded health insurance plans organized by state to serve high-risk people who meet enrollment criteria and can’t get group insurance. Because the health law now requires most health plans to cover people with pre-existing conditions, several states have been considering whether or not to close their high-risk pools.

Medicaid, Indian Health Services, dependents of active duty US military, or other government aid programs

These types of programs are available for young adults who meet the requirements for them. Still, some states exclude full-time students from these programs if the programs work mostly with low-income people.

While you are looking for health insurance

One of the most important things a patient can do before a procedure or treatment is to discuss costs and negotiate a price for the care up front. Don’t be afraid to ask your doctor or hospital for a discount – reducing your health care costs by any amount will help, even if you have insurance. Start with your hospital billing office, and find out who else besides the hospital might bill their services. This is most important for people who aren’t insured, because they typically don’t get the discounts that are negotiated by insurance companies and are often charged the highest prices.

Check into Hill-Burton funds

A few hospitals and other non-profit medical facilities get Hill-Burton funds from the federal government so they can offer free or low-cost services to those who can’t pay. Each facility chooses which services it will provide at no or lowered cost. Medicare and Medicaid services aren’t eligible for Hill-Burton coverage. But Hill-Burton may cover services that other government programs don’t.

Eligibility for Hill-Burton is based on family size and income, and availability of a Hill-Burton facility. You will first need to find out if there’s a facility in your area that has any Hill-Burton obligation for which you may qualify. If you are cared for at such a facility, you may apply for Hill-Burton help at any time, either before or after you receive care. For more information, visit their website, www.hrsa.gov/hillburton. There you can find a listing of Hill-Burton-obligated facilities, eligibility criteria, and frequently asked questions about the program. Or you can call 1-800-638-0742 for a packet of information.

Compare your drug list to low-cost prescription programs

Some drugstores, grocery store pharmacies, and discount stores now offer certain generic drugs at very low prices. Most of the time, these do not include cancer drugs – although some offer tamoxifen and other such drugs in their programs. Even people with insurance may be able to lower their co-pays and save money by getting some generic medicines at very low cost (often $4 to $10 for each refill).


Last Medical Review: 11/04/2014
Last Revised: 11/04/2014