Health Insurance Rights of Cancer Survivors

Types of health insurance

It's vital for cancer survivors to have health insurance they can depend on. There are many kinds of policies. But not all of them offer enough coverage.

It's best to have comprehensive health insurance. It should pay for all your basic healthcare needs. These needs include hospital and healthcare provider care, lab tests, scans, medical equipment, and prescription medicines. To decide if a policy meets your needs, find out the monthly cost (premium). Then look at:

• Exactly which services are covered and which are excluded

• How much you have to pay for covered services (may be copays or coinsurance)

• If your providers, specialists, and pharmacy are covered (in network)

• If medical care is limited to a certain medical system or network

• If your medicines are covered (Are they included on the plan's drug formulary?)

• The annual deductible (This is the amount you must pay each year before the plan starts covering certain services.)

Be wary of insurance that's not comprehensive. These types of policies may be good supplemental policies. This means you have them along with your comprehensive coverage. But alone, they don't provide enough coverage for cancer survivors. These include:

• Catastrophic coverage plans

• Medical savings accounts or health savings accounts

• Critical illness or cancer insurance

• Hospital indemnity policies

• Cancer insurance and other supplemental insurance

Getting and keeping private health insurance

You have rights under federal and state laws to help you buy and keep insurance. But these rights vary. For instance, they may depend on where you live or the kind of plan you have or want.

Who regulates my insurance?

To learn about your rights, it helps to find out who regulates your kind of health insurance. State rules control many plans sponsored by small employers. They also control most insurance you buy on your own. But some health insurance is controlled by rules from the federal government. This includes most health plans offered by large employers. Your protections will vary depending on whether state or federal rules apply. Your protections also vary depending on:

• Whether you are in a group health plan or buying your own individual health insurance

• Changes to state and federal health laws made by elected officials

Your rights under a group plan offered by an employer

If you are offered a group health plan, you have rights under federal and state law. These include:

Nondiscrimination. Your right to be covered under a group health plan can't depend on how healthy you are now or have been in the past. This means you can't be refused health benefits under an employer's health plan if you are a cancer survivor.

Affordable Care Act (ACA). Under the ACA, insurers must offer open enrollment periods during which all applicants must be accepted, no matter what their health is. This part of the ACA also stops insurers from using a person's health history to set monthly premiums.

COBRA. COBRA is a federal law. It lets you and your family stay covered under your group health plan when you leave your job and in certain other cases. You, your dependents, or both can stay in the group plan for a limited period for at least 18 or up to 36 months, depending on the qualifying event. When you sign up for COBRA, you have to pay the full premium. This includes the part the employer used to pay for you.

Your rights under an individual plan

The rights you have when buying your own health insurance depend on where you live. State laws vary. Talk with your state insurance commissioner's office for more information. Or go online to use a consumer guide that outlines the rights in each state. State-specific policies are published by Georgetown University. They're available at chir.georgetown.edu.

Public health insurance

In some cases, you can get health insurance from the government. This is instead of insurance from an employer or insurance company. Some public programs are described here:

Medicare

Medicare is health insurance provided by the federal government. You qualify if any of these apply to you:

• You are 65 or older and get Social Security benefits

• You are disabled (at any age) and have had Social Security disability income (SSDI or SSI) for two years

• You have ESRD (end-stage renal disease) or permanent kidney failure that needs regular kidney dialysis or have had a kidney transplant (at any age)

Medicare is divided into parts. Parts A and B are Original Medicare that's provided through Social Security. The other parts must follow rules set by Medicare but are run by private insurance companies.

Medicare parts include:

• Part A. This is hospital insurance. It covers inpatient care you get in a hospital and some other care centers, such as a skilled nursing facility. For most people who qualify for Medicare, there's no premium for Part A. But you will have to pay a deductible for each hospital stay. For longer stays in a hospital or nursing home, you will have to pay coinsurance.

• Part B. This is medical insurance. It covers service charges from healthcare providers , lab fees, home health care, durable medical equipment, many preventative services, and other outpatient care. You pay a monthly premium for Part B. There's also a deductible for covered services and co-insurance. Usually, you don't need a referral to use a specialist.

• Part C. This is a combination of Parts A and B provided by private insurers. These private insurers must be approved by Medicare. They must provide all hospital and medical benefits covered by Medicare. These policies are called Medicare Advantage Plans. They charge a monthly fee. Some include the Part D medicine plan (see below). Some also cover extra things, like vision and dental care, which are not part of Original Medicare. Part C is not available everywhere. You may need to get a referral to use a specialist.

• Part D. This part is optional. It helps pay for prescription drugs. If you join, you pay a monthly fee. The amount varies by plan. You also pay a yearly deductible and part of the cost of your prescriptions. This includes a copayment or coinsurance. Costs depend on which plan you choose.

Many people buy extra insurance to pay for costs Medicare does not cover. This is sometimes called Medigap.

Medicare can be very confusing. This is often the case for Parts C and D. It's best to talk with an independent expert before buying a Medicare Advantage Plan or Medigap insurance. You might want to visit the Medicare  website. It has tools to help you learn more about what's available where you live, get an idea of plan costs, and find a plan that fits your needs.

Medicaid

Medicaid is a shared federal and state program. It provides health insurance for low-income people and families. There are federal rules that states must meet to get federal funds. Each state has the right to develop its own Medicaid program.

In most states, to qualify for Medicaid you must:

• Have very low household income

• Be a child, a parent, or an elderly adult

• Have a disability

• Must be a U.S. citizen, national, or satisfy immigration status

Some states have expanded Medicaid programs to cover low-income adults who aren't elderly, disabled, or parents.

You can find Medicaid information for your state at Medicaid.gov.

Other public health insurance

Some states have more help for people who can't afford health insurance. This is in addition to Medicaid. A few states have other plans that you can buy at lower premiums if you have low income. Some states have high-risk pools. In these, you might be able to buy coverage if a private insurer turns you down. Again, these vary a lot from state to state.

Using your health insurance

When you need to use your health insurance, keep these things in mind:

• Know what rules you must follow. For instance:

  • You may need a primary care provider. This is the person who you'll see for wellness exams and sick visits. In some plans, it's also the person who will refer you to specialists when that level of care is needed.

  • You may need referrals in order to see a specialist.

  • You might be restricted to certain providers or hospitals—those that are "in network." Going out of network might mean you pay more. Or your claim may even be denied.

  • You might need to submit a claim within a certain number of days in order for it to be paid.

• Keep good records. This includes copies of all bills, EOBs (explanations of benefits), and other correspondence. Ask for names, addresses, and phone numbers of people you talk to. Write down the dates and key points of your conversations.

• If a claim is denied, appeal it. Appeal it again and again if you have to. Ask your provider to help you make your case. Keep records of all your correspondence. Keep track of all time deadlines. You may only be able to appeal a denial within a certain number of days after the decision. If you are in a state-regulated plan, you may be able to appeal to an outside panel of experts.

Other rights you have

You also have rights about:

• Privacy of your health information. The government protects your right to private health information under a law called HIPAA (Health Insurance Portability and Accountability Act of 1996). For information on your rights, see the U.S. Department of Health and Human Services.

• Affordable Care Act (ACA) enrollment. The ACA has an open enrollment period each year. If you miss that, you may qualify for a special enrollment period. Find out more about ACA insurance here.