January 2011 Ask the Expert: Understanding Health Insurance Options
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.
Ms. Amato: I am not aware of any price controls.
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 condition 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.
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.
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 condition clauses.
Ms. Amato: I don't think you will have any trouble with pre-existing condition 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.
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.
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.
Ms. Amato: BCCTP is a Medicaid program for higher income or working women. You can re-apply to Medicaid 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.
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.
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 therapy in the home, you may not be able to win an appeal.