January 2011 Ask the Expert: Understanding Health Insurance Options

January 1, 2011

If you have been diagnosed with breast cancer or you are at high risk for breast cancer, getting a grasp on your insurance policy and benefits can help you plan ahead and get the most possible coverage from your policy.

It can be difficult to stay informed about our constantly changing healthcare system. Because most of us aren’t forced to navigate our insurance coverage until we face a serious illness, it is easy to get confused. If you don’t have health insurance, you may be feeling scared and overwhelmed at the thought of paying for care.

During the month of January 2011, Living Beyond Breast Cancer expert LuanneAmato, MBA, answered your questions about how to navigate your current insurance policy, or what to do if you are unable to work, leave your job or are uninsured.

You may also be interested in reading our Guide to Understanding Financial Concerns.

Question: I am on COBRA after becoming unemployed. I have 7 months left. I am also on unemployment. I was diagnosed with advanced breast cancer in August. I am not sure if I should go on disability after my unemployment runs out and before my COBRA runs out. What are the pluses and minuses?

Ms. Amato: If you are approved for disability, they may extend COBRA benefits that you can purchase. Once the COBRA benefits run out, you will have to buy your own health insurance.

Question: My state's law requires insurers to pay for reconstruction for breast cancer patients who have mastectomies. Are insurers required to pay for subsequent revision surgeries (such as where there is capsular contraction around an implant)?

Ms. Amato: Insurers that cover reconstruction will pay for revision surgeries that are related to the primary mastectomyinfo-icon.

Question: I do not have access to group health insurance. During a recent move to a new state, I had difficulty finding a private plan that I could afford, given my health history (breast cancer, back surgeries, arthritis). Are there any controls on what insurance companies can charge for private policies?

Ms. Amato: I am not aware of any price controls.

Question: Pre-existing conditions are often excluded from [health insurance] policies through riders, creating problems for those of us with [a history of] significant health [problems]. Isn't removal of those exclusions a part of healthcare reform?

Ms. Amato: Healthcare reform will begin prohibiting insurers from denying coverage to children because of a   pre-existing condition for children beginning September 2011. Insurers will not be prohibited from denying coverage to adults because of a pre-existing conditioninfo-icon do not have to include adults until January 1, 2014.

However, the government has put into place a new program as a stop-gap measure until 2014. You must be without health insurance for 6 months and be a U.S. citizen. It The program is based on your state regulations. In Pennsylvania, it is known as Fair Care.

Question: What affordable options are there for individuals with [a] significant history [of health problems] who are not denied insurance but “priced-out” of the market? State plans require being denied insurance and being without coverage for 6 months, and [there are] still no guarantees you'll be accepted.

Ms. Amato: There is a website that you can access for health quotes from several leading companies.

Unfortunately, your comments about state plans are correct. Unless you can qualify for Medicaid, you will have to look in the marketplace.

Question: I have been on "medical leave" for 2 years while being treated for breast cancer. I no longer have my job, but [I] have been fortunate enough to still be given group rates on the insurance. I will soon be starting the job search—Hooray!—but if unable to get a job with benefits, is there a good insurance that is affordable for a single woman who has had invasive breast cancer?

Ms. Amato: Please research this website for local individual plans, and do some shopping. But be sure that you disclose your medical conditioninfo-icon.

Question: I am currently on long term disability and full insurance benefits with my employer and will be starting SSDI in March 2011. My employer will eventually drop my insurance coverage, and I will not be able to afford COBRA. What are my other options?

Ms. Amato: Because you are on SSDI, there are not many options. You must be on SSDI for two years before you are eligible for Medicare. You could shop around or apply for Medicaid if you qualify. Please view this website for help with insurance plans.

Question: Effective 1/1/11, I learned I did not have health insurance due to my spouse's company being sold. I [have had] Medicare Part A since my cancer diagnosis in 2002. What options do I have? Part A only pays for hospitalization. I need doctor visits and drug coverage.

Ms. Amato: Apply for Medicare Part B. Once you have been approved, you can get a replacement plan that includes the additional 20 percent not covered by Medicareinfo-icon as well as drug coverage.

Question: I am a 63-year-old breast cancer survivor. I am unemployed and just lost my COBRA due to closing of the company. I would like to find a reasonable health insurance that will also transfer to Florida since I may need to move back there for financial reasons, however I know this is very tricky. Can you help? I am having real problems financially so moving back to Florida would be a great help, but I've been told I'm uninsurable unless I set it up from this end. I feel like I live in a 3rd world country where I can't cross between borders!

Ms. Amato: Are you eligible for Medicare, which can be transferred anywhere? If not, you should shop for private plans.

Question: I had insurance when undergoing breast cancer surgery and chemo treatments in 2006. I lost my job 2 years after and am currently uninsured. My current job does not offer insurance benefits. Are there any affordable options for me in the state of Tennessee? I would not qualify for insurance … that is [based on] financial need.

Ms. Amato: You will need to go to the state website and find out what plans are available that you may be eligible for given that you have been uninsured for over 6 months. If you can’t find a state-sponsored coverage, then you should shop for private plans.

Question: I have [Blue Cross] Special Care at $180/mo. It is all I can afford. My daughter is covered under CHIP. I just finished eight rounds of chemo for stage II breast cancer and 6 1/2 weeks of radiation. I need better insurance as Special Care only pays for 4 doc visits per year, and my lifetime limit of diagnostics has been reached. What are my other affordable options at this point? Adult Basic is a fortune. In about 5 months, I will be eligible for Wegmans (my employer) health insurance, but [I am] worried about the pre-exisiting conditions. What to do????????

Ms. Amato: At this point, you should reach out to the financial counselors or social workers at the facility where you are receiving treatment for other options. BC Special Care is the most reasonable option.

I don’t believe you will have a problem with Wegmans. Usually group base plans for employers do not include pre-existing conditioninfo-icon clauses.

Question: I had no health benefits when I was diagnosed and was fortunate enough to meet the income requirements to be put on PA Medicaid through the Breast and Cervical Cancer Treatment Fund (BCCTF). It covers the tamoxofin and mammograms/MRIs I'll continue to need for the next 3 years. I am currently looking for a full time job with health benefits; however, I am worried about pre-existing condition messiness with employer-sponsored insurance. Is this a legitimate concern? Also, I may move to California for family reasons if a job here in PA doesn't come through soon. Do pre-existing condition insurance laws vary from state to state? My doctor says I should be able to transfer my BCCTF coverage to CA until I get a job with health benefits out there, do you know if this is true?

Ms. Amato: I don't think you will have any trouble with pre-existing conditioninfo-icon clauses in an employer-based insurance; most businesses do not have them. You should ask if there are any clauses in their contract before accepting a position. If there is a pre-existing condition clause, be sure to ask how long it is in effect. Usually it has a waiting period—for instance, one year.

If you move to California you will have to re-apply for BCCTF in that state, but I don't think you will have any problems with the transfer.

Pre-existing condition clauses can vary from state to state, so make sure you always ask the question when the time arrives for you to be offered insurance. I am not familiar with the norm in California. By the year 2014, we will see an end to pre-existing condition clauses under the new healthcare reform package.

Question: I have health insurance through Health Partners of MN and am paying COBRA premiums due to a divorce two months before I was diagnosed with breast cancer. My COBRA is $740.00 per month. Is there any help out there to assist me with that monthly premium?

Ms. Amato: My suggestion would be to get in touch with your local representative—most states have different funds to help patients with specific diagnoses and some will even help with COBRA premiums. These change from state to state; that is why I suggest you get in touch with your local representative for your area who will be able to guide you to any assistance available to you.

Question: I have a Medicare supplement from Humana, and my co-pays have doubled just because it's now 2011. Same treatments, same drugs, same place, same doctor, same Medicare supplement plan but double the co-pays. What can be done about that?

Ms. Amato: There is not really anything you can do about the co-pays a plan requires. Your only option is to shop around and find another supplement plan that offers lower co-pays that are within your budget. There are many plans out there, and they all have to follow the guidelines of what each plan covers. For example, all Part A plans cover the same things, but there are no guidelines as to what the insurance charges for this coverage.

Question: When first diagnosed in Sept 2006, I was underinsured unbeknownst to me. My doctor …. worked with me to get my treatments and surgeries covered under the federal [Breast and Cervical Cancer Treatment Program] (BCCTP). In late 2008, I had phase I of breast reconstruction. Phase II was scheduled, but I had to cancel it because I was severely ill and my blood [was] bad. There was no choice but to postpone the final surgery until I was well. My unfinished breasts cause me much distress. In the meantime, I was declared eligible for [Social Security Disability Insurance] (SSDI) and had to switch to Medicare even though I am 49 yr old. My oncologist says my blood is now good. My secondary illness is in remission, and I want have my breasts finished. My problem is Medicare pays 80 percent, and I am responsible for the other 20 percent. I am single and have gone through all my savings and retirement funding over the past four years. I am in collections since Medicare took over my health coverage. What can I do as I cannot afford to finish my breast reconstruction?

 Ms. Amato: BCCTP is a Medicaid program for higher income or working women. You can re-apply to Medicaidinfo-icon with lower income information, and you can use as a secondary insurance. Your second option would be to go to the facility where you had you surgeries and inquire about the Patient Assistance Program for patients who have financial hardships.

Question: I have stage IV inflammatory breast cancer, HER2+. I have had two skin recurrences since my initial diagnosis. I retired on June 4, 2010, after a year on medical leave. I get my disability retirement and [Social Security Disability Insurance] (SSDI). I was also getting a few hundred a month from the [long term disability] (LTD) policy I carried through my employer. I just got a letter from the LTD company, saying that payments are being discontinued because I do not have severe side effects from my medications and that my last PET/CT showed improvement. How do I appeal this?

Ms. Amato: I would call the LTD company and find out the appeal process. You should also review your policy or have the company send you a copy of the benefits that outline this exclusion. I don’t understand how the LTD policy can be cancelled for side effects.You may want to call your former HR department for assistance also.

Question: I have Horizon Blue Cross Blue Shield of New Jersey and have had my appeal denied to obtain the Flexitouch lymphedema system to use at home. I have truncal edema (breast, chest, side, upper arm). What can I do?

Ms. Amato: There is a second level appeal process that you should have been advised of when the first appeal was denied. Also, is the insurance company providing you with options outside the home? If they are, you may not win an appeal because they are providing you with other options. Unless you can support a reason for having therapyinfo-icon in the home, you may not be able to win an appeal.