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February 2014 Ask the Expert: Understanding Health Insurance Options

Understanding your health insurance can be confusing and overwhelming. Knowing what rights you have as a person with breast cancer can be a challenge. During the month of February, Living Beyond Breast Cancer expert Stephanie Fajuri, JD, answered your questions about health insurance and breast cancer, how your health coverage may change because of the Affordable Care Act, and how to choose an insurance plan that meets your needs as a person with breast cancer.

Remember: We cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical advice.

I’m a young, newly diagnosed woman and am transitioning to a new job. If my old job and new job offer insurance coverage through the same company, will I have to wait for the probationary period to be over to use my insurance or will my coverage automatically begin?

I’m currently covered by Medicaid, and I’m not old enough for Medicare. My state did not expand Medicaid coverage, so what should I do to be prepared for when the program I’m on now ends?

I’m a survivor of 13 years. My daughter has never had a mammogram and doesn’t have health insurance. What are her options for free mammograms or other help?

I am going on medical leave because of metastatic disease.  Our family health insurance is through my employer. If I do not return to work, is my only choice COBRA?

If COBRA is the only choice of health insurance coverage I have, do I have to put my family on it or can I enroll them in a marketplace plan available through the Affordable Care Act?

Can I enroll in an Affordable Care Act marketplace plan for 2015 even though I can technically have COBRA coverage for 18 months? We would qualify for subsidies and it would be cheaper than sticking with COBRA.

Why doesn't health insurance cover the bandages and compression garments I require because of damage done to my lymphatic system during breast cancer treatment?

Can you claim disability because of cancer?

My last radiation treatment was Jan. 2014. When I change jobs, will it be honest to say that I do not have DCIS anymore? 

I am BRCA1 positive and my doctor recommended a yearly MRI in addition to my mammogram. I thought the MRI would be fully covered due to my BRCA1-positive status, but last year I paid $600 out of pocket. They said the lack of full coverage was related to the Federal Employees Plan I have through my employer and that I needed to write to the Office of Personnel Management to contest it.  Do you have any other advice you can give me?

Are health insurance companies obligated to cover the cost of breast reconstruction after a mastectomy? If a person decides to also have a contralateral prophylactic mastectomy is it usually covered by health insurance, along with reconstruction?

What are your thoughts on a $250 deductible before the insurance will pay for prescriptions? 

Question: I am a 27 year-old woman just diagnosed with breast cancer and currently transitioning to a new job. I have health insurance through Blue Cross/Blue Shield and my new job, which I start in a couple of weeks, also offers coverage through BCBS. Because I will be a new employee, will I have to wait for the probationary period to be over to use my insurance? Or, because of my diagnosis, will my coverage automatically begin? 

Ms. Fajuri: Many employers have a probationary period (usually 3 months or less) before new employees are eligible for the employer-sponsored health insurance plan. You should stay on your current BCBS plan during that probationary period (and continue paying your premiums), and then can switch over to your new employer’s plan. 

Because of healthcare reform (also known as Obamacare), insurance policies can no longer impose a pre-existing condition exclusion period where you would not have coverage for your pre-existing condition for a period of time. Your new BCBS plan through your employer has to cover you, including your breast cancer treatments.

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Question: Right now my treatments for breast cancer are covered by a Medicaid plan. I'm not old enough for Medicare and don't know what to do when the program I'm on now ends. My state did not expand Medicaid. I only work part-time in the summer. What should I do to be prepared?

Ms. Fajuri: Unfortunately, your situation highlights that there are still some gaps in the healthcare law and illustrates why it is so important for states to expand their Medicaid programs. Once your program ends, if you are making more than 100% of the Federal Poverty Level (about $11,000 for a single person this year), you could look into purchasing health insurance through healthcare.gov or through your state’s health insurance marketplace/exchange, as you would likely be eligible for significant health insurance premium tax credits that would make your insurance more affordable.  

Unfortunately, if you make less than 100% or more than 400% of the FPL, your other option would be to try to purchase an insurance plan either through any insurance company in your state or though the insurance exchange – but you wouldn’t qualify for health insurance premium tax credits.

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Question: I am a breast cancer survivor of 13 years. My question is about my daughter who is 42 years old, does not have health insurance and has not had a mammogram. Can you please tell me her options for a free mamo or any other kind of help? 

Ms. Fajuri: First and foremost, your daughter should look into getting health insurance ASAP! The Affordable Care Act requires most US citizens and legal residents to have health insurance coverage for most of the year or pay a penalty. However, one great part about the law is that it also requires new insurance policies to offer certain preventive services (like mammograms, or for those who are concerned about a possible genetic link to cancer, BRCA genetic counseling) with no co-pay and without having to meet a deductible. 

So, if your daughter gets on a new health insurance plan, she likely would be able to access those services at low or no cost.  If she doesn’t make enough money to afford a health insurance plan, she should look into whether or not she might qualify for Medicaid or another program, such as the Breast and Cervical Cancer Treatment Program.

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Question: I am going on medical leave because of metastatic disease.  Our family health insurance is through my employer. If I do not return to work, is my only choice COBRA?

Ms. Fajuri: While COBRA does offer you the opportunity to stay on the same insurance that you have through your employer, it’s no longer your only option.  If you become eligible for COBRA, you will also have the opportunity to purchase an insurance policy through healthcare.gov or through your state’s insurance marketplace/exchange.  If your household income is between 100% and 400% of the Federal Poverty Line (FPL), you might be eligible for health insurance premium tax credits if you purchase insurance through the exchange. 

However, if your household income is above that, you can still purchase insurance either through the exchange or through any private insurance provider in your state.  Becoming eligible for COBRA puts you into a special enrollment period for the health insurance marketplace/exchange, and you generally only have 60 days to opt into COBRA coverage, so make sure you pay attention to important enrollment deadlines.

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Question: If COBRA is the only choice of health insurance coverage I have, do I have to put my family on it or can I enroll them in a marketplace plan available through the Affordable Care Act?

Ms. Fajuri: COBRA is no longer your only choice!  Health insurance providers are no longer allowed to discriminate against applicants for having a pre-existing condition,so if you are on COBRA now, you could potentially purchase a different insurance policy either through the marketplace or through any private insurance company in your state. 

Open enrollment for the health insurance marketplace currently goes through March 31, 2014, and purchasing through the marketplace is the only way to potentially get health insurance premium tax credits. However, if you choose to stick with COBRA for yourself, you do have the option of putting your family on a separate plan.

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Question: Can I enroll in an Affordable Care Act marketplace plan for 2015 even though I can technically have COBRA coverage for 18 months? We would qualify for subsidies and it would be cheaper than sticking with COBRA.

Ms. Fajuri: Even though COBRA gives you the option of staying with the same insurance plan you had through your employer for up to 18 months, you aren’t obligated to stay on it that entire time! If it would be less expensive to be on a plan through the marketplace because you qualify for subsidies, you can look into signing up at any time before March 31, 2014, when open enrollment ends. If you wait until after March 31, you would have to wait until the next open enrollment period to be able to sign up for a plan through the marketplace and be able to get the subsidies.

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Question: Why doesn't health insurance cover the bandages and compression garments I require because of damage done to my lymphatic system during breast cancer treatment? 

Ms. Fajuri: You should double check your summary plan description to find out exactly what your health insurance policy covers, as some policies cover medical devices in a different way than they might cover certain treatments or medications.  

If your policy does cover these items, but your insurance company is refusing payment, you can work with your doctor to appeal the insurance decision, emphasizing that the bandages and compression garments are medically necessary.  

Because of the Affordable Care Act, almost everyone now has the right to both an internal appeal and external appeals process, so even if your insurance company denies your appeal initially, you might be able to appeal their decision to an independent third party.

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Question: Can you claim disability because of cancer? 

Ms. Fajuri: When it comes to “claiming” disability, it’s important to clarify whether you are looking to purchase a disability insurance policy,  trying to access benefits from a private policy you already hold, or trying to access state or federal disability benefits. 

If you want to purchase a disability insurance policy and have already been diagnosed with cancer, please keep in mind that disability insurance companies can still discriminate based on pre-existing conditions, as the Affordable Care Act does not apply to them. Therefore, it might be difficult to purchase a private disability insurance policy if you’ve already been diagnosed. 

However, if you are looking to access disability benefits, whether or not you can qualify for disability benefits because of your cancer will depend on how severe your condition, symptoms,  or reactions to treatments are. It might also depend on how long your condition or symptoms are expected to last. 

If you want to apply for disability insurance benefits through a private policy that you have on your own or through work, you will have to look at your specific policy to see how it defines the term “disability.”  

If you’re looking to apply for disability benefits through the Social Security Administration (SSA) or through a state disability insurance program, your disability might have to be expected to last for a certain period of time. For SSA purposes, it’s generally at least a year. If your condition is affecting you at work but not to the point where you are no longer able to work at all, keep in mind that you might be able to ask for accommodations in the workplace under the Americans with Disabilities Act or a state fair employment law.

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Question: I was diagnosed with DCIS. My last radiation treatment was Jan. 2014. When I change jobs, will it be honest to say that I do not have DCIS anymore? 

Ms. Fajuri: You are not under an obligation to disclose any current or previous medical conditions that you may have had to an employer, even prospective employers!  For several years, insurance companies have not been allowed to exclude people with pre-existing conditions from employer-sponsored health insurance plans. That said, they were able to impose exclusion periods where they might not have covered the pre-existing condition for a period of time. 

However, due to protections offered by the Affordable Care Act, there should be no reason to have to disclose any previous medical conditions. Insurance companies are no longer able to ask about medical history or impose exclusion periods. Should you need accommodations in the workplace as a result of your history with DCIS, you might be asked to fill out a medical certification form. You would be required to provide enough information to show why you need the accommodation, but would never have to disclose your actual diagnosis.

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Question: I am insured by the Federal Employees Plan of Blue Cross Blue Shield. I had triple-negative breast cancer in 2010. I am BRCA1 positive and my doctor recommended a yearly MRI in addition to my mammogram. I thought the MRI would be fully covered due to my BRCA1-positive status, but last year I paid $600 out of pocket. When I called Blue Cross, they said the lack of full coverage was related to the Federal Employees Plan and that I needed to write to the Office of Personnel Management to contest it. I have not done that yet. Do you have any other advice you can give me?

Ms. Fajuri: You should look at your summary plan description to confirm your coverage options and see whether or not your plan explicitly states that the test would not be covered. If your insurance policy says that certain tests are not covered, you have a few options. You can appeal or complain to the insurance company — which it sounds like you have already done — to try to get the test covered as a medical necessity. Your doctor might be able to help you with this. If that doesn’t work, you can try to speak with your employer (or, in your case, the Office of Personnel Management) to see if you can get them to expand coverage. You might also want to see whether there are other Federal Employee Health Insurance plans offered to you that might cover the yearly MRI. 

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Question: Are health insurance companies obligated to cover the cost of breast reconstruction after a mastectomy? If a person decides to also have a contralateral prophylactic mastectomy is it usually covered by health insurance, along with reconstruction?

Ms. Fajuri: Under the Women’s Health and Cancer Rights Act of 1998 (WHCRA), group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy and coverage also must provide coverage for all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications from the mastectomy, including lymphedema.  

WHCRA also applies to lumpectomies. However, WHCRA does not apply to Medicare or Medicaid, and it does not require coverage of prophylactic mastectomies.  Health insurance companies have varying policies about whether or not they will cover prophylactic surgery, and the criteria used to determine whether these procedures are medically necessary may vary as well. However, generally if the insurance policy covers prophylactic mastectomy, it must also cover the reconstruction. If you are considering prophylactic surgery, you should discuss coverage issues with your doctor and insurance company before making a decision. 

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Question: What are your thoughts on a $250 deductible before the insurance will pay for prescriptions? 

Ms. Fajuri: We can’t speak to affordability of your prescriptiondrug plan. Although many prescription drug insurance policies require co-pays every time you get a prescription (for example, $20 for certain covered drugs every time you have a prescription filled), some policies do require a deductible be met before they will pay for prescriptions. It is up to the insurance provider to decide how much of a pharmacy deductible to have, if any.  

If you aren’t satisfied with your prescription drug policy, you might be able to purchase a different health insurance policy that offers better prescription drug benefits, such as through the health insurance marketplace. Additionally, there are many prescription drug assistance programs that exist for those who are struggling to afford their medications, so check with the pharmaceutical company that manufactures your medications to see if they can offer any assistance.

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Denver, CO  ·  September 13, 2014

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