Changes to our Health Care System under President Trump

changes to our health care system under President TrumpTriage Cancer believes that access to affordable, quality health insurance coverage and medical care is critical to improving the health and well-being of the cancer community.  To that end, we will continue to provide you with updates on what is happening in Washington, D.C. and in states across the country, with respect to any changes to our health care system under President Trump, and how those changes may impact the cancer community.

Webinar on Wednesday

On Wednesday, January 25, Triage Cancer is partnering with the National Coalition of Cancer Survivorship on a webinar to bring you the latest news: Affordable Care Act Update: What Advocates and Cancer Survivors Need to Know.

What Happened in the Last Week

On Friday, President Trump took office and that afternoon, signed an executive order regarding The Patient Protection and Affordable Care Act (ACA).  This executive order does not repeal the ACA, but it does allow agencies to waive or defer provisions that “impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.”

While there are few details in this executive order, it is broad enough to allow a number of potential significant changes. For example, under this order, the IRS could stop enforcing the requirement that people have health insurance coverage, referred to as the “individual mandate.”

Second, Republican Senators Susan Collins and Bill Cassidy introduced the Patient Freedom Act of 2017. The Senators claim that their bill will: return power to the states; increase access to quality, affordable health care for all Americans; improve patient choice; and begin to bring coverage to the nearly 30 million Americans who still do not have health insurance.  As we get additional details about this legislation we will share it with you.

Understanding the Possible “Replacements” & Other Changes

There is a great attention being paid to the repeal of the ACA, but there are other changes being discussed. Over the last few weeks, we have laid out how those changes may impact the cancer community in these blogs:

We also want to share some other resources that you may find helpful:

We hope that our elected officials will keep these issues in mind as they make their decisions over the next few days, weeks, and months on any changes to health care system.

What You Can Do

We will have to continue to wait and see what happens, but in the meantime, there is something that you can do.

Share your experience and concerns: Call or email your elected officials and share your health insurance concerns. To find your elected officials or learn more about becoming an advocate, visit our Advocacy resources. You can also find the Facebook and Twitter handles for the current members of Congress here.

Tell your story: Share your story with Families USA or the National Coalition of Cancer Survivorship (NCCS), two health care advocacy organizations that are working to help our elected officials understand the dire consequences of repealing the ACA and how certain changes to our health care system can impact us all. But they need the stories of real people. If you feel comfortable doing so, you can share your story at http://familiesusa.org/share-your-story at www.canceradvocacy.org/blog/share-your-aca-story.

Do You Need Health Insurance Now?

We also want to remind you that change is Washington is rarely swift and that we may not see changes for most of 2017.  That means that we have to continue to operate with the system we have for now and ensure that people have health insurance coverage for 2017.  If you do not have health insurance coverage, you can apply for Medicaid at any time or purchase a policy through the State Health Insurance Marketplaces until January 31, 2017.

For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar. If you aren’t sure what your health insurance options are, you can get personalized information on our recently released resource: www.CancerFinances.org.

Stay Tuned

Stay tuned to our Blog and sign up for our newsletter, as we will continue to provide updates as more information becomes available in the coming days, weeks, and months.

Post-Election Update: How health insurance may be changing

how health insurance may be changingAs we have reported since the election, changes to our health care system are likely to occur in 2017 and beyond.  While we wait for further action by Congress, we will continue to provide you with information about some of the the possible changes to our health care system and how we get health insurance.

Here are 4 ideas that we have heard from Republican leadership: President-elect Donald Trump, Speaker of the House of Representatives Paul Ryan, and Senate Majority Leader Mitch McConnell:

  1. Provide Medicaid block grants to states
  2. Allow insurance companies to sell policies across state lines
  3. Provide tax credits for purchasing health insurance coverage
  4. Regulate drug prices

Let’s break down what these ideas may actually mean.

  1. Provide Medicaid block grants to states

Currently, Medicaid is funded through a matching system, with the federal government paying for part of the expense of providing Medicaid coverage and states picking up the rest of the cost. There currently isn’t a limit on the amount of funds a state can receive to meet the health care needs of its population.

A block grant is a fixed dollar amount to provide coverage for a state’s health care needs. When the money runs out, that’s it.  This greatly increases the chances that people would go without care.  For example, imagine a year where winter storms are particularly harsh and the flu season is extreme. This would increase the number of people in a particular state that need medical care. What would happen if the state has already spent its Medicaid funds by the end of November? Would no one receive medical care in December?

While the argument in favor of Medicaid block grants is to give states more flexibility to improve their Medicaid programs, in reality, a Medicaid block grant system would likely cause states to have to make tough decisions: a) reduce the number of people eligible for Medicaid; b) reduce the coverage available through Medicaid; or c) both.

Click here to learn more about why block grants only sound like a good idea.

There would also be an impact on hospitals and health care providers. In states that have expanded access to Medicaid, there are fewer uninsured people in those states.  When people are uninsured and need medical care, the burden is often placed on hospitals and health care providers to cover the cost of that “uncompensated care.” If uninsured individuals can’t pay their medical bills, then providers are the ones who suffer. Over the last few decades, many hospitals have had to close, because they can’t afford to cover that uncompensated care. The ACA reduced the amount of uncompensated care by increasing the number of people with health insurance coverage. A Medicaid block grant program would likely increase the number of people without health insurance coverage, increase uncompensated care, and place the burden back on health care providers.

And just to wade a little further into the weeds . . .

If individuals with more expensive pre-existing conditions don’t have access to Medicaid in their state, then they are more likely to enter the individual health insurance market.  Those individuals are most expensive to ensure, and insurers pass on those costs to everyone, which increases the cost of insurance for everyone. This has proven to be the case now. In states that expanded access to their Medicaid programs, the cost of premiums for individual plans in their state health insurance marketplace were, on average, 7% lower than in states that did not expand access to Medicaid.

  1. Allow insurance companies to sell policies across state lines

While there are some federal laws, like the Affordable Care Act (ACA), which provides consumers protections in health care, there are also state laws that provide protections. Those state laws can offer protections such as coverage mandates. For example, a state may require an insurance company to cover oral chemotherapy at the same rate as IV chemotherapy, to reduce the out-of-pocket expenses for patients. Some states even give their insurance commissioner the power to reject excessive monthly premiums charged by insurance companies.

The problem with selling health insurance policies across state lines, is that it provides a loophole that allows insurance companies to not comply with certain state law requirements and offer less comprehensive coverage. Watch this great video which explains why selling insurance across state lines may sound like a good idea, but really poses some practical challenges.

  1. Provide tax credits to help people purchase health insurance coverage

Speaker Ryan’s “A Better Way” proposal suggests offering an “advanceable, refundable tax credit for individuals and families.” Making the purchase of health insurance tax deductible would be very helpful for many people in the United States.  However, for those with lower income levels, it does not sufficiently help those individuals get the money to buy adequate health insurance coverage in the first place. In addition, given the possible repeal of the ACA, whether there will be individual health insurance policies to buy is still unclear.

  1. Regulating drug prices

The cost of prescription drugs has been skyrocketing for decades, partly due to the significant scientific advances that have been made. It was proposed during the election to lower the cost of drugs through regulation. Watch this video to learn more about why regulating drug prices sounds like a good idea, but may not work the way we hope. The devil really is in the details.

We hope that our elected officials will keep these issues in mind as they make their decisions over the next few days, weeks, and months on any changes to health care system.

What You Can Do

We will have to continue to wait and see what happens, but in the meantime, there is something that you can do.

  1. Share your experience and concerns: Call or email your elected officials and share your health insurance concerns. To find your elected officials or learn more about becoming an advocate, visit our Advocacy resources page. You can also find the Facebook and Twitter handles for the current members of Congress here.

 

  1. Tell your story: Share your story with Families USA or the National Coalition of Cancer Survivorship (NCCS), two health care advocacy organizations that are working to help our elected officials understand the dire consequences of repealing the ACA and how certain changes to our health care system can impact us all. But they need the stories of real people. If you feel comfortable doing so, you can share your story at http://familiesusa.org/share-your-storyor at canceradvocacy.org/blog/share-your-aca-story.

Do You Need Health Insurance Now?

We also want to remind you that change is Washington is rarely swift and that we may not see changes for most of 2017.  That means that we have to continue to operate with the system we have for now and ensure that people have health insurance coverage for 2017.  If you do not have health insurance coverage, you can apply for Medicaid at any time or purchase a policy through the State Health Insurance Marketplaces until January 31, 2017.

For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar. If you aren’t sure what your health insurance options are, you can get personalized information on our recently released resource: www.CancerFinances.org.

Stay Tuned

Stay tuned to our Blog and sign up for our newsletter, as we will continue to provide updates as more information becomes available in the coming days, weeks, and months.

Post-Election Update: Are HSAs a health care solution?

As we anxiously await further action by Congress, we want to continue to share with HSA Health Care Solutionyou some of the possible changes to our health care system.  Today we are talking about if high deductible health plans and Health Savings Accounts (HSA) are a health care solution.

High Deductible Health Plans

A high deductible health plan is a health insurance plan that has a very high deductible. A deductible is a fixed dollar amount that you have to pay before your health insurance coverage begins. You could have a $0 deductible or a $10,000 deductible, depending on the plan that you choose.  This applies to plans that you might get through your employer or a plan that you would get from an insurance company. Now, when we say “high” deductible that is going to mean something different to each of us. But generally, in 2017, a high deductible health plan can have a deductible of $1,330 or more. But some plans have deductibles as high as $7,000. This means that you have to pay your $7,000 deductible out-of-pocket first, before your health insurance coverage kicks in.

The ACA did guarantee access to some preventive care and immunizations without having to pay a deductible, but if the ACA is repealed that protection might also go away.

Having to pay $7,000 or more before your health insurance coverage starts is something that most people would find difficult. And that is what contributed to the problem of medical bankruptcy. Prior to the ACA, 62% of all bankruptcies in the US were based on medical debt. And 78% of those individuals that had to file bankruptcy because of their medical bills actually had health insurance. Their higher out-of-pocket costs forced them into filing bankruptcy. Higher out-of-pocket costs also cause people to go without medical care.

On the other hand, the benefit to a high deductible health plan is that the monthly premium is usually lower. This might be a useful plan option if you are healthy and don’t need ongoing medical care. But, if you have a serious medical condition like cancer, you will likely pay more out-of-pocket with this type of coverage.

Health Savings Accounts or HSA’s

One way to deal with the costs of this type of coverage is by also choosing a Health Savings Account or HSA. A health savings account is a personal savings account where you can save money to pay for your medical expenses, including your deductible. There are significant tax benefits of having this account, because you don’t pay taxes on the money that you put in your HSA (up to a certain amount each year). The downside is that you actually have to have money to put in the HSA to use to pay your deductible and other medical expenses. And the concern is that most people don’t have the ability to save that kind of money to pay for their medical expenses.

Click here for a detailed overview of how high deductible health plans work with health savings accounts, and whether or not this is a realistic solution for individuals and families with lower incomes.

We hope that our elected officials will keep these issues in mind as they make their decisions over the next few days, weeks, and months on any changes to health care system.

What You Can Do

We will have to continue to wait and see what happens, but in the meantime, there is something that you can do.

  1. Share your experience and concerns: Call or email your elected officials and share your health insurance concerns. To find your elected officials or learn more about becoming an advocate, visit our Advocacy resources page. You can also find the Facebook and Twitter handles for the current members of Congress here.
  1. Tell your story: Share your story with Families USA or the National Coalition of Cancer Survivorship (NCCS), two health care advocacy organizations that are working to help our elected officials understand the dire consequences of repealing the ACA and how certain changes to our health care system can impact us all. But they need the stories of real people. If you feel comfortable doing so, you can share your story at http://familiesusa.org/share-your-storyor at canceradvocacy.org/blog/share-your-aca-story.

Do You Need Health Insurance Now?

We also want to remind you that change is Washington is rarely swift and that we may not see changes for most of 2017.  That means that we have to continue to operate with the system we have for now and ensure that people have health insurance coverage for 2017.  If you do not have health insurance coverage, you can apply for Medicaid at any time or purchase a policy through the State Health Insurance Marketplaces until January 31, 2017.

For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar. If you aren’t sure what your health insurance options are, you can get personalized information on our recently released resource: www.CancerFinances.org.

Stay Tuned

Stay tuned to our Blog and sign up for our newsletter, as we will continue to provide updates as more information becomes available in the coming days, weeks, and months.

Post Election Update: Changes to Medicare

Established in 1965, Medicare now covers nearly 48 million seniors and an additional 9 Changes to Medicaremillion people with disabilities. For information about Medicare, read our previous blogs or our Quick Guide to Medicare. Congressional leaders have indicated that there are changes to Medicare on the way.

Medicare’s benefits can be accessed in two ways. Through traditional Medicare, services are covered as fee for service.  Meaning that you can get medical care from any provider that accepts Medicare coverage.  Alternatively, Medicare Advantage is a way to get Medicare coverage through a managed care plan (HMO or PPO). These managed care plans are offered by private health insurance companies and have specific networks of providers that are covered by the plan.

Throughout the contentious election season, President-elect Donald Trump, promised to preserve Medicare as is.  However since the election, key Republican leaders have proposed changes to Medicare.

For example, U.S. Congressman Tom Price, a noted conservative who was recently nominated to be the next U.S. Secretary of Health and Human Services (HHS), has proposed, among other changes, moving Medicare to a voucher system. This would mean giving each individual a voucher worth a certain amount of money to go and buy private health insurance coverage.  There are a number of potential challenges with this approach for consumers:

  1. If the ACA is repealed, many of the consumer protections will no longer be available
  2. It is unclear if the amount of the voucher will be enough to actually buy coverage. If it isn’t then individuals will have to pay more for their health insurance than they were paying under Medicare
  3. It is unclear what the individual health insurance market will look like and what plan options will be available
  4. It is unclear if those options will provide equal coverage to Medicare
  5. As seniors and people with disabilities often have higher medical expenses, they may be charged more for their coverage and plans may be too expensive for people to buy

Congressman Price’s nomination to lead HHS, which has control over Medicare, has caused many to question the validity of President-elect Trump’s campaign promise to protect Medicare.

Speaker of the House Paul Ryan has also championed a voucher system, which he calls “premium support.”  In his 2016 proposal entitled “A Better Way,” Ryan makes several recommendations. Under his plan, the Medicare eligibility age would be raised from 65 to 67 by 2020.  Then in 2024, “Medicare beneficiaries would be given a choice of private plans competing alongside the traditional Medicare program on a newly created Medicare Exchange.” Increasing subsidies for Medicare Advantage and allowing private insurers to offer a variety of coverage levels is suggested as well.  Unfortunately, consumers who choose plans with more comprehensive coverage and flexibility may be required to pay the difference.

Some economists say that a privatized Medicare Advantage would be more efficient and enhance benefits to consumers while decreasing the cost to taxpayers.  Other experts say that Medicare would not automatically be more efficient if privatized. They argue that Medicare already efficient and the projected savings privatized Medicare Advantage was supposed to provide have not materialized.

Additionally, both Price’s and Ryan’s proposals leave out important details.  For instance, how much money would be given to individuals to purchase insurance? Would benefits be guaranteed?  How would the quality of coverage be monitored and ensured?  Would subsidies increase in proportion to the rising cost of healthcare?

Exactly what, if any, changes will be implemented is still unclear.  Not every member of Congress who is committed to repealing the Affordable Care Act, also thinks that making changes to Medicare should be their top priority.  Those who do want to make changes to Medicare have different opinions on how to do so.

One thing is certain: these proposed changes have caused considerable anxiety for Medicare recipients and their advocates. Triage Cancer will continue to follow this issue and share information as we receive it. Stay tuned to our blog and newsletter for the latest information.

Important News Regarding Changes to Medicare

medicaredotgovThe new year will bring changes to Medicare.  Click here to see what Medicare will cost in 2017.

Also, if you recently became eligible for Medicare, but thought it would be less expensive to keep your Marketplace coverage because you get financial assistance to pay for your Marketplace coverage, then the rest of this message is for you. 

When you became eligible for Medicare Part A (the hospital portion of Medicare that is usually premium-free), you also became ineligible for Marketplace financial assistance. So that means you will be on the hook for the full price of the Marketplace plan. This also means that you probably missed the open enrollment period for Medicare Part B (the other part of Medicare coverage that has a premium). And, it means that if you do try to get Medicare Part B now, you will pay a late enrollment penalty for the rest of your life.  But . . .

For a limited time, you can apply for “equitable relief” that will give you a Special Enrollment Period to enroll in Part B. It also means that they won’t apply a late enrollment penalty, but you must apply by MARCH 31, 2017!

Some of you in this situation may have been notified of this program by mail. But it you weren’t notified, or lost the notice, or even feel you received misinformation about qualifying for financial assistance, you should contact the Social Security Administration (800-772-1213) to apply for the “equitable relief.”

Your application should include:

  • Any information or documentation you have on how you learned that the financial assistance would not apply and/or why you thought you could continue financial assistance.
  • Any letters (including the notice mentioned above), emails, notes from conversations
  • Or any other relevant information

And more good news – you don’t need to show that your confusion was caused by any particular source to qualify for this relief. You can just be confused.  We know health insurance is confusing!

To learn more about Making Sense of the Medicare Mazewatch our recorded webinar.

Why Pre-Existing Condition Protections Are Not Enough

Over the last week, we have continued to hear about proposed changes to our health triage cancer blog pre-existing conditioncare system from the President-elect and members of Congress.  Some of those changes would have a significant impact on the cancer community. Next week, we will start to break down how those changes might impact the cancer community. However, this week, we wanted to talk about pre-existing conditions.

What is a Pre-Existing Condition?

“Pre-existing condition” used to be a term that only health insurance companies and health law attorneys used. The Patient Protection and Affordable Care Act (ACA) made that term more common, because the ACA prohibited health insurance companies from denying coverage to anyone with a pre-existing condition. A pre-existing condition is any medical condition that exists before the health insurance policy begins; the condition “pre-exists” the policy. A pre-existing condition is often thought of as a serious medical condition, such as a cancer diagnosis.  But prior to the ACA, insurance companies would routinely deny coverage to anyone with conditions such as arthritis, allergies, asthma, or even acne. Really, any medical condition was a reason for denial. And this had a huge impact on the cancer community. Over the close to two decades that we have worked in the cancer community before the passage of the ACA, we  would often have to to tell people that they didn’t have any option to access health insurance coverage because of their pre-existing condition.  The ACA changed that.

This change to our health care system was so significant that most people don’t want to see that portion of the ACA repealed. The President-elect and the Speaker of the House have both said that they would want to continue to provide protections for people with pre-existing conditions.  However, they have not provided details on whether they would do that by keeping the ACA rule, or create some other option.

Last week, we highlighted a few of the consumer protections in the ACA, some of which apply to plans offered by employers, plans offered through the State Health Insurance Marketplaces, and individual and family plans that you can buy directly from an insurance company.  Those consumer protections would be lost if the ACA were to be repealed.

Assuming that they keep the rule that ensures people with pre-existing conditions can purchase insurance, that rule by itself, isn’t enough to protect consumers, and here’s why:

  1. Coverage: the ACA ensures that plans have a minimum level of essential health benefits.
    1. Without this protection, people with pre-existing conditions might still be able to buy a plan, but the coverage might be minimal (like not covering mental health care or prescription drugs).
  2. Caps on benefits: the ACA does not allow insurance companies to place annual or lifetime caps on essential health benefits.
    1. Without this protection, people with pre-existing conditions might still be able to buy a plan, but the plan might cap benefits at $100,000 for the year, or $1 million for a lifetime, or even lower, leaving people to pay for medical expenses out of pocket.
  3. Rescissions: the ACA forbids health insurance companies from canceling your policy, unless your commit fraud on your application or leave off important information.
    1. Without this protection, people with pre-existing medical conditions might find their policies cancelled after submitting an expensive claim that the health insurance company doesn’t want to pay.
  4. Prevention: the ACA requires most health plans to provide free preventive care.
    1. Without this protection, we will go back to having to pay co-pays, co-insurance amounts, and deductibles when receiving preventive services, and many people will be forced to forgo that care.
  5. Out-of-pocket maximums: for plans sold in the Marketplaces, the ACA placed a cap on how high the out-of-pocket maximums could be, which greatly reduced out-of-pocket costs for people with pre-existing conditions.
    1. Without this protection, people will likely see even higher out-of-pocket medical costs.

And finally . . .

  1. Price: the ACA requires US Citizens, and those lawfully present in the US, to have health insurance coverage (with some exceptions).
    1. Without this requirement, many who are not currently in need of medical care, will not buy health insurance coverage, leaving only people with pre-existing conditions buying coverage. If we do not have a balanced risk pool, which includes people who are healthy as well as people with more serious medical conditions, then health plans will likely increase monthly premiums for everyone. In addition, if those people who are healthy wait until they get sick to buy coverage, that will further skew the risk pool and increase premiums even more. If the plans are too expensive to buy, then it won’t matter that people with pre-existing conditions are “allowed” to buy health insurance coverage.

We hope that our elected officials will keep these issues in mind as they make their decisions over the next few months on any changes to health care system.

What You Can Do

We will have to continue to wait and see what happens, but in the meantime, there is something that you can do.

  1. Share your experience and concerns: Call or email your elected officials and share your health insurance concerns. To find your elected officials or learn more about becoming an advocate, visit our Advocacy resources page. You can also find the Facebook and Twitter handles for the current members of Congress here.
  1. Tell your story: Share your story with Families USA or the National Coalition of Cancer Survivorship (NCCS), two health care advocacy organizations that are working to help our elected officials understand the dire consequences of repealing the ACA and how certain changes to our health care system can impact us all. But they need the stories of real people. If you feel comfortable doing so, you can share your story at http://familiesusa.org/share-your-story or at canceradvocacy.org/blog/share-your-aca-story.

Do You Need Health Insurance Now?

We also want to remind you that change is Washington is rarely swift and that we may not see changes for most of 2017.  That means that we have to continue to operate with the system we have for now and ensure that people have health insurance coverage for 2017.  If you do not have health insurance coverage, you can apply for Medicaid at any time or purchase a policy through the State Health Insurance Marketplaces until January 31, 2017. If you want your policy to begin on January 1, 2017, you need to have picked a plan by December 15, 2016.

For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar. If you aren’t sure what your health insurance options are, our recently released toolkit, Finances 101, may be useful.

Stay Tuned

Stay tuned to our Blog and sign up for our newsletter, as we will continue to provide updates as more information becomes available in the coming weeks and months.

Do You Need a Special Policy for Cancer?

Some employers offer supplemental health insurance policies to cover the costs that your Triage Cancer Blog Cancer Policytypical health insurance policy doesn’t. These policies could cover things related to a “critical illness” or a specific medical condition, like cancer.

These are policies that your employer pays for as part of an employee benefits package, or that you can buy directly from the insurance company through your employer.  AFLAC would be an example of a company that offers these policies.  If you aren’t sure if this type of policy is available to you at work, you’re your human resources representative, or whomever handles the employee benefits at work.

Depending on where you live, you may be able to buy a supplemental cancer insurance plan directly from an insurance company.

Be aware

Before you considering buying a supplemental plan, here are some things that you should consider.

  • The two types of policies
    • There are two different types of cancer insurance plans. The first is very similar to a typical health insurance plan in that it pays for a certain portion of your medical expenses. The second pays a predetermined lump-sum for various expenses, such as transportation and lodging when you need to travel to receive treatment. It may also pay cash payments when you have surgery or receive other types of medical care. The lump sum payments can be used for anything, including your daily living expenses.
  • Different plan = different coverage
    • Depending on the cancer insurance plan, a policy can cover a lot of medical and nonmedical expenses, including co-pays, hospital stays, treatments, fertility preservation and dietary assistance. However, there are very few plans that will cover this range of expenses. Additionally, they won’t pay for costs that are already covered by another health insurance plan.
  • Critical illness insurance is a reasonable option
    • Some insurance providers offer critical illness insurance along with a cancer plan. This kind of insurance provides coverage for strokes, heart attacks, and other critical illnesses.
  • You may not be able to purchase cancer insurance if you had cancer in the past
    • If you have been diagnosed with or treated for certain kinds of cancers or other medical conditions in the last three or five years, some companies will deny you coverage The protections against pre-existing condition denials that are available for regular health insurance coverage, do not apply to these supplemental plans.
  • Know your history
    • A family history of cancer may be a good indication to purchase cancer insurance for yourself of your family members.
  • Cancer insurance is not a stand-alone product
    • Cancer insurance is meant to cover the gaps in your regular health insurance plan, not serve as a stand-alone product to cover your medical expenses.
  • Read the fine print
    • Read everything before you buy a policy because many have gaps in the terms. For instance, some policies’ coverage kicks in months after purchasing while others stop paying out after a certain time.

Clinical Trials and The Cost

triage-cancer-blog-clinical-trials-costOne of the first questions you or your loved one should consider when thinking about participating in a clinical trial is the cost and whether your medical insurance will cover it.  There is not one answer to this question, but let’s look at a big picture.

In most cases, when a patient enrolls in a clinical trial, the study sponsor provides the new treatment at no cost and pays for any tests, procedures, or doctor visits. Some sponsors go even further and pay for things like travel time and mileage.  It is important to find out what cost are covered by the study and if you will be stuck with any of the expense.  At this point, you also should look at your insurance coverage.

Private Insurance

As of January 1, 2014, the Patient Protection and Affordable Care Act required that non-grandfathered health plans (i.e. those that were not in place before March 23, 2010) cannot deny a qualified individual participation in an approved clinical trial, or deny or limit the coverage of “routine costs” in connection with participation in the trial.  An “approved clinical trial” is deemed as one that test ways to prevent, detect, or treat cancer and are funded or approved by the federal government and have submitted an FDA Investigational New Drug application (IND) or are exempt from IND requirements.  Routine costs” are those that would normally be involved in standard of care, such as doctor visits, blood tests, imaging scans, etc.

State laws may go even further in protecting consumers’ rights to participate in clinical trials.  Thirty-seven states and the District of Columbia all have laws on the books regarding clinical trial coverage.  For specific information about your state, go to http://TriageCancer.org/statelaws.

Medicaid

Unfortunately, the federal government does not require states to cover clinical trials through state Medicaid plans, so coverage depends on the state in which you live.  For specific information about your state, go to http://TriageCancer.org/statelaws.

Medicare

Like private insurance, Medicare covers routine costs of items and services in covered research studies. Examples of these items and services include room and board at a hospital, the treatment of side effects and complications that may occur as a result of the study, and operations to implant an item that is being tested.  For a full understanding of Medicare coverage for clinical trials, go to https://www.medicare.gov/Pubs/pdf/02226.pdf.

TRICARE and Veterans Affairs

Our military members and families also have some coverage for clinical trials.  TRICARE will reimburse the medical costs related to taking part in National Cancer Institute (NCI) sponsored trials for cancer prevention and treatment.  Veterans Affairs allows eligible veterans to participate in NCI-sponsored clinical trials at VA Medical Centers.

There is good news out there about clinical trial coverage, but you have to your due diligence.  Make sure you ask what the study covers and then get a full understanding of what your insurance covers.

For more information about participating in a clinical trial, visit http://triagecancer.org/clinical-trials or read other blogs in this series at http://triagecancer.org/blog.

Appealing an Insurance Company’s Decision

triage-cancer-blog-appealsOne of the more frustrating aspects of cancer treatment is dealing with the insurance industry.  We pay our monthly premiums with the expectation that when and if the time comes, we will receive coverage for our medical care.  Sadly, it’s not always as turn-key as that.  Sometimes, claims are denied or we are charged more than we think we should be paying under our policies.  At that point we have to fight for our coverage.  This process is called an appeal (note: some companies call this a grievance).  There is an internal appeals process and an external appeals process.

Internal Appeals

Your insurer must notify you in writing if they deny your claim for coverage:

  • Within 15 days if you are seeking prior authorization for a treatment
  • Within 30 days for medical services already received
  • Within 72 hours for urgent care that you have not yet received

If you disagree with a decision your health plan has made, you have the right to file one of two types of internal appeals:

  1. Expedited Appeal

An expedited, or urgent appeal is filed if you have not received any treatment yet, or if you are in the middle of treatment and you or your doctor believe that your condition could involve imminent or serious threat to your health.  Obviously, this is an urgent matter, so your health plan should respond to your appeal within 72 hours of getting a qualifying appeal.  They will notify you by phone, as well as in writing.

  1. Standard Appeal

If your situation does not meet the standard for an expedited appeal, you still have the right to an appeal.  This process is longer, as your health plan will inform you of their decision, in writing, within 30 calendar days from the date they receive an appeal.

In both cases, your appeal will be reviewed by the appropriate administrative and/or clinical specialist.  These specialists will not have been involved in the initial decision or a subordinate of the person who made the initial decision.

What to Include in Your Appeal?

When preparing your appeal, but sure to include all the necessary information.  This means the member name and ID number, the name of the provider who will or has provided the care, the dates of service, the claim reference number for the specific decision you are appealing, and the precise reason you disagree with the initial decision.  You have the right to include any documents, comments or other materials that are relevant to your appeal.

You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external appeal at the same time as your internal appeal.

If your insurance company denies your internal appeal, you can file for an external appeal.

External Appeals

Under the Affordable Care Act (ACA) and some state laws, you not only have the right to appeal a decision within your insurance plan, but you also have the right to ask for an external review.  This means that an external, independent, specialist will review your appeal and the insurance plan no longer has final say over whether to pay a claim.  Keep in mind, you can ask for an external review if your internal appeal was denied or was not satisfactorily resolved within the 30 days or 72 hours, in cases of an expedited appeal.

All states are required to participate in an external review process that meets the consumer protection standards of the ACA. Your state may also have an external review process that is more protective. In California, which has some the strongest consumer protections in the county, this means going to http://hmohelp.ca.gov.  To find out about the external review process in your state, visit: http://triagecancer.org/resources/stateresources/.

If your state doesn’t have an external review process that meets the minimum consumer protection standards, the U.S. Department of Health and Human Services (HHS) will oversee your state’s external review process for health insurance companies. If your state relies on an HSA-administered external review, you can begin that process in four ways:

  1. Call 1-888-866-6205 to request an external review request form. Then fax an external review request to: 1-888-866-6190.
  2. Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
  3. Submit a request via email: is ferp@maximus.com
  4. At some point in the near future you will be able to request an external review online at externalappeal.com

Ideally, you will not need any of this information.  However, if you do, take heart.  Thanks to the ACA, there are strong consumer protections available in every state and we see an average of approximately 50% of external appeals of denials get successfully overturned.

Buying Supplemental Insurance Can Be Hard For Younger Medicare Beneficiaries

by, Kasier Health News

Danny Thompson’s kidneys have failed and he needs a transplant but in some ways, he’s lucky: Both of his sons want to give him one of theirs, and his Medicare coverage will take care of most of his expenses.

Yet the 53-year-old Californian is facing another daunting obstacle: He doesn’t have the money for his share of the medical bills and follow-up drugs, and he can’t buy supplemental insurance to help cover his costs.

“It’s frustrating to be in the shape I’m in,” said Thompson, who depends on dialysis instead of his kidneys to cleanse his blood. “My plan is to get a transplant so I can go back to work.”

Almost one in four Medicare beneficiaries has such a policy, known as Medigap, which is sold by private insurance companies. It can help pay for costs Medicare doesn’t cover, including the 20 percent coinsurance required for medical expenses, including certain drugs, plus deductibles and co-payments. Those expenses have no out-of-pocket limit for beneficiaries.

Federal law requires companies to sell Medigap plans to any Medicare beneficiary aged 65 or older within six months of signing up for Part B, which covers doctor visits and other outpatient services. If they sign up during this guaranteed open enrollment, they cannot be charged higher premiums due to their medical conditions.

But Congress left it to states to determine whether Medigap plans are sold to the more than 9 million people younger than 65 years old who qualify for Medicare because of a disability.

In 20 states and the District of Columbia, home to more than 2 million disabled Medicare beneficiaries, insurers are not required to sell Medigap policies to customers under 65. In other states, insurers cannot reject applicants if they enroll when they first join Medicare. Companies in some states, including Virginia, can still charge higher premiums to younger beneficiaries or those with kidney disease, often making policies unaffordable.

In California, Massachusetts and Vermont. insurers are required to sell Medigap policies to anyone with Medicare, except to people like Thompson who are under 65 and have end stage renal disease.

“If it was the reverse — if you were discriminating against somebody because they were 65 or older as opposed to younger — people would be outraged,” said Bonnie Burns, policy specialist for the consumer group California Health Advocates and a member of the National Association of Insurance Commissioners’ Medigap committee.

The federal health law provides no relief for these younger Medicare beneficiaries. One of its most popular provisions prohibits discrimination by insurance companies in the non-Medicare market based on pre-existing conditions or age, but the law is silent on Medigap.

Thompson, who lives in Menlo Park, near San Francisco, said 12 Medigap insurers have turned him down. Buying a health plan through Covered California, the state’s health insurance exchange, is not an option since he has primary insurance through Medicare. “That is for people who don’t have insurance, and I have insurance,” he said. “But it is as if I don’t.”

The transplant costs are substantial, and Thompson said he does not have the resources to cover his share. Kidney transplant patients can expect the preparation, surgery, tests and treatment for the first year to run more than $262,000, according to the American Kidney Fund. The immunosuppressant drugs, which patients will need for the rest of lives to ensure their body does not reject the new kidney, cost another $2,000 to $4,000 a month.

No Hospital Mandate

Hospitals and doctors are not required to provide care for Medicare patients unless it’s a medical emergency, a Medicare official said.

Joe Baker, president of the Medicare Rights Center, said that they can turn away Medicare patients for any number of reasons, including inability to pay their share of the bills or because providers are not taking new patients.

“Medicare beneficiaries under 65 with end stage renal disease get an organ transplant if they agree to pay their share of the costs Medicare doesn’t cover,” said Lisa Kim, a spokeswoman for Stanford Hospital, where Thompson has sought treatment.

To help Thompson find financial assistance, a Stanford social worker referred him to Christina Dimas-Kahn, who heads the San Mateo County office of the California Department of Aging’s Health Insurance Counseling and Advocacy Program (HICAP). She said he is one of several clients with end stage renal disease that HICAP counselors have tried to help in the past few years, “But people with the disease don’t have whole lot of options if they are under 65,” she said.

Danny Thompson, 53, needs a kidney transplant and both of his sons want to give him one of theirs (Heidi de Marco/KHN).

Thompson needs a kidney transplant and both of his sons want to give him one of theirs. (Heidi de Marco/KHN)

Thompson recently learned that he could qualify for Medi-Cal, California’s Medicaid program for low-income people, which Dimas-Kahn said would cover his transplant expenses. But Thompson said that coverage would kick in only after he paid a $2,500 deductible every month, which he cannot afford.

If Thompson divorced his wife of 30 years, her income wouldn’t be counted along with his Social Security disability benefits and it’s possible he wouldn’t have to pay the deductible. That’s not a good alternative, he said. “We made vows — rich or poor, in sickness or in health — you stay married.”

‘Crazy Patchwork’ Of Regulations

Another solution could be moving to another state, such as Delaware. That’s where Heather Block, a politically savvy project manager for federal and international organizations, took on her state legislature after she was diagnosed with advanced breast cancer.

“I considered myself lucky when I became eligible for Medicare but that 20 percent co-pay with no out-of-pocket maximum is exorbitant for anyone let alone someone with a serious illness,” she said.

Block could get Medicare before turning 65 because she qualified for disability benefits, but she couldn’t get Medigap coverage. Two years ago, she spearheaded a successful campaign to change state law, forcing insurers to sell Medigap policies to anyone when they first enroll in Medicare regardless of age, without basing rates on their health conditions.

“It is insane that we have to go through this crazy patchwork of state regulations,” said Block, whose monthly charges for cancer drugs alone range as high as $9,800. Without Medigap, medical bills would eventually deplete her savings.

Prospects for a nationwide solution are dim because expanding Medigap coverage could lead to these beneficiaries with disabilities receiving more care and raising costs for the Medicare program. Congress is looking for strategies to curb Medicare spending, not increase it, Burns said.

The health insurance industry’s trade association opposes expanding Medigap to include all Medicare beneficiaries younger than 65 with end stage renal kidney disease. Since treatment for those patients can be so expensive, adding them could increase Medigap premiums for everyone, said Cindy Goff, a vice president at America’s Health Insurance Plans. She pointed to Medicare statistics that show when the program covers patients over 65 with end-stage renal disease, their care averages nearly nine times more than other Medicare beneficiaries.

Older adults are “super price-sensitive” and raising premiums “would basically price them out of being able to get the Medigap protection they want,” said Goff.

“The insurance company knows that these patients coming through the door are going to use services,” said LaVarne Burton, president of the American Kidney Fund. “In most instances, if they don’t get treatment, they will die.”

This post originally appeared at Kaiser Health News on February 3, 2016.