Can I Get Health Insurance If I Have Cancer?

How does the ACA help lower costs?

The ACA offers important protections. For example, a health insurance company:

• Cannot deny you coverage, charge you more, or refuse to cover essential health benefits because of pre-existing conditions, such as cancer, that you had before the new health coverage starts. However, this may not apply to certain plans, including grandfathered plans and short-term limited duration plans.
• Must limit the amount an individual or family has to pay out-of-pocket each year.
• Cannot charge women more than men.
• Cannot require pre-authorization for emergency care. They also cannot charge you higher out-of-pocket fees if you receive emergency care from an out-of-network health care provider or emergency department.

If you have a grandfathered health insurance plan, these protections may not apply to you. Your insurance provider is required to tell you if your plan is grandfathered, but ask them if you’re not sure.

The ACA also provides for more low-cost options in certain situations:

• If your work only offers a health insurance plan that’s not affordable, you may be able to get financial help to buy a more affordable plan through your state’s Health Insurance Marketplace.
• If your income is low enough, you may be able to sign up for Medicaid. This depends on the rules of your state.

You may also be able to get financial help to lower monthly costs through premium tax credits.

What are essential health benefits?

Essential health benefits are types of care that the ACA requires most health plans to cover. They include:

• Outpatient care (care you get without being admitted to the hospital)
• Emergency care
• Inpatient care (care you get when you are admitted to the hospital)
• Pregnancy, maternal, and newborn care
• Mental health and substance abuse disorder care
• Prescription drugs
• Rehab care and devices (recovery of daily living skills)
• Lab tests
• Preventive care, such as screening mammograms and colonoscopies
• Children’s health

The ACA reduces the cost of some of these services. Some are even required to be provided at no cost.

Where can I find health insurance if I have cancer?

The Health Insurance Marketplace offers health insurance plans that people can buy directly. Other options will depend on where you work and any government programs you qualify for.

The Health Insurance Marketplace

Plans available through the Marketplace meet ACA rules about providing people easy-to-understand details about coverage.

The ACA also helps set up the process for buying health insurance through the Marketplace. People can choose a plan during the yearly open enrollment period. They may also sign up during a special enrollment period if they have a qualifying life event, such as having a baby, or if household income drops.

Marketplace health plans vary in price based on your income, family size, and which state you live in. There are many plans to choose from. Learn more at HealthCare.gov.

Employer insurance

Employer-sponsored health insurance, sometimes called group insurance, is offered through your job. Employers usually pay part of the cost, which reduces the overall costs for the employees. Under the ACA, you can’t be denied coverage based on health history or charged more because of a pre-existing condition, such as cancer. These plans usually cover a range of services, including preventive, emergency, hospital, and office visit care. They also cover prescription medicine costs, although the exact types and amounts vary between plans. The ACA also reduces out-of-pocket costs.

Depending on the plan, your spouse and children might be covered under your employer’s plan. Costs are usually lower than if you were to buy an individual plan on your own.

If you lose your job or are not able to work, you have the right to continue your health coverage under COBRA (the Consolidated Omnibus Budget Reconciliation Act). This coverage can start on the day your employer-sponsored insurance ends. However, the cost is higher because you would be paying the full costs without your employer contributing to the cost.

Medicare

Medicare covers people with pre-existing health conditions, including cancer. If you qualify, you can’t be denied based on your health. There are some important details that need to be reviewed to find out if you are eligible, such as age and disability. Learn more in Does Medicare Cover Cancer Treatment?

Medicaid

Medicaid covers people with low income and pre-existing health conditions, including cancer. If you qualify, you can’t be denied based on your health. Usually, Medicaid covers a wide range of services such as doctors’ visits and treatments, but this may vary by state. Learn more in Medicaid for People With Cancer.

Veterans Affairs health care and TRICARE

If you’re a veteran, active-duty service member, or part of a military family, you may qualify for coverage through VA health care or TRICARE. These programs offer a range of coverage, including for pre-existing health conditions. Coverage and benefits may depend on your service history and status. Learn more about what is covered in US Military Veterans and Cancer.

Can I get insurance if I lose my job?

The Consolidated Omnibus Budget Reconciliation Act (COBRA), also called Continuation of Health Coverage, lets many people keep their workplace health insurance for a limited time after losing coverage because of certain life events, such as:

• Losing a job
• Leaving a job
• Having work hours reduced

If you have coverage through a spouse or parent’s job, you can also qualify for COBRA if you lose coverage because of other life events, such as:

• Death of the primary insured individual
• Divorce or legal separation from the covered employee
• Loss of dependent status when you turn 26
• Becoming Medicare eligible

After a qualifying event, your health plan administrator should send you a COBRA election notice explaining your rights and how to enroll. You generally have 60 days to decide whether or not to choose COBRA coverage. The coverage can apply retroactively within that 60 days to prevent a gap in coverage. In most cases, COBRA coverage lasts up to 18 months, although some people might qualify for longer coverage periods. Also, the employer must have at least 20 employees for COBRA to be in effect.

Choosing between COBRA and Marketplace coverage

With COBRA, you usually keep the same doctors, network, and benefits you had through your work plan. But you might have to pay the full monthly premium yourself, plus a small administrative fee, which can make COBRA more expensive than what you had to pay while working.

You might also have the option to buy a health plan through the Marketplace. Losing job-based coverage qualifies you for a special enrollment period, which usually lasts 60 days. Depending on your income and household size, a Marketplace plan might cost less than COBRA and might offer financial help to lower monthly premiums. You can also enroll 60 days prior to loss of COBRA.

Before choosing between COBRA and a Marketplace plan, compare:

• Monthly premium costs
• Deductibles and out-of-pocket costs
• Provider networks and covered services
• Prescription drug coverage

If you switch to a Marketplace plan, your deductible and out-of-pocket maximum will usually reset. If you keep COBRA, the amounts you have already paid toward your deductible and out-of-pocket limit for the current plan year generally continue. This is an important consideration for people who have already started cancer treatment. If you have already paid much of your deductible or are close to your out-of-pocket maximum for the year under your employer coverage, it might make sense to finish the year with that plan, even though you would need to pay the entire premium.

What if I’m also eligible for Medicare?

If you are eligible for Medicare, delaying Medicare enrollment because you chose COBRA could lead to late enrollment penalties or gaps in coverage.

Insurance shopping tips for people with cancer

As you’re reviewing options, keep in mind that some health plans may not start right away. This could delay treatment or leave you with high costs if you need care before coverage starts.

Also, be aware that out-of-pocket costs such as co-pays may be high for certain plans.

If you’re deciding between getting insurance through your employer or getting individual insurance, here are a few things to think about:

If your employer’s health coverage premiums will cost you more than a certain percentage of your monthly income, you might be able to find a better deal in your state’s Marketplace. The income percentage used to decide affordability can change with inflation, so check healthcare.gov for the most current rate. If you choose not to get health insurance through your employer, you can also sometimes get help with premiums on the Marketplace if your income is below this set percentage.

In some cases, your employer’s health plan may be affordable for you, but the cost to add coverage for your family may not be. In that case, you may be able to use your job-based plan for yourself and look for a more affordable Marketplace plan for your spouse or dependents.

When reviewing possible health insurance plans:

• Check to make sure your doctors and treatment are in-network
• Check to make sure your prescription drugs are covered
• Find out your costs for co-pays, deductibles, and out-of-pocket limits
• Be sure you know when coverage will start

If you’re having trouble understanding your options, you can:

• Get help from Marketplace assisters or navigators to learn about plans
• Talk with your social worker or patient navigator about financial help and resources such as nonprofit organizations, state, and local programs