counseling and resource center for cancer patients - serving the east end free of charge

Insurance and Financial Assistance

When you are diagnosed with cancer, the right healthcare insurance plan can make a big difference. If you lack sufficient healthcare coverage, understanding the insurance system and where you can go for additional financial support may go a long way in reducing your concerns.

There are three “typical” ways people secure health insurance in the United States. Many employees receive health insurance benefits through their employers. Others who do not have health insurance through an employer may purchase health insurance privately.

Finally, there is a system of federal and state-funded health insurance coverage.

Employee-based Health Insurance
Read your policy carefully! Every insurance company is different!

The majority of insurance companies that provide insurance through employers cover standard cancer treatments such as radiation, chemotherapy and surgery.

In order to best understand what your insurance covers, be sure to review the literature your employer and insurance company have given you describing your benefits. Compile all questions that you may have about your coverage and review them with the benefits administrator at your place of employment and a representative from your insurance company.

Please keep in mind as you compile your information that there are five federal laws dealing with your healthcare rights:

ERISA (Employment Retirement Income Security Act of 1974)
ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.

COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986)
COBRA gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.

ADA (Americans with Disability Act of 1990)
ADA prohibits discrimination against people with disabilities in employment, transportation, public accommodation, communications, and governmental activities.
www.ada.gov

FMLA (Family and Medical Leave Act of 1993)
FMLA is designed to help employees balance their work and family responsibilities by allowing them to take reasonable unpaid leave for certain family and medical reasons. It also seeks to accommodate the legitimate interests of employers and promote equal employment opportunity for men and women. The Family and Medical Leave Act provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.

HIPPA (Health Insurance Portability and Accountability Act of 1996)
HIPPA provides rights and protections for participants and beneficiaries in group health plans. HIPAA includes protections for coverage under group health plans that limit exclusions for preexisting conditions; prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances. HIPAA may also give you a right to purchase individual coverage if you have no group health plan coverage available, and have exhausted COBRA or other continuation coverage.

For more information on these programs please visit the following website:
http://www.dol.gov/dol/topic/health-plans/index.htm

Federally Funded Insurance Programs
Federally Funded Insurance usually falls under two main categories: Medicare and Medicaid.

Medicare
Available for people who are 65 years or older and/or those who are disabled for more than 2 years, legally blind or on renal dialysis. Co-pays and/or deductibles are required for treatments and services.

Medicare Part A
Medicare Part A helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits.

Medicare Part B
Medicare Part B helps cover medical services like doctors’ services, outpatient care, and other medical services that Part A doesn’t cover. Part B is optional. Part B helps pay for covered medical services and items when they are medically necessary. Part B also covers some preventive services like exams, lab tests, and screening shots to help prevent, find, or manage a medical problem.

Medicare Advantage Plans or Part C
Medicare Advantage Plans are health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called “Part C.” They provide all your Part A and Part B coverage and must cover medically-necessary services. They generally offer extra benefits, and many include Part D drug coverage. You may have to see doctors who belong to the plan or go to certain hospitals to get covered services.

Medicare Part D
Medicare Part D is prescription drug coverage offered to everyone with Medicare. This coverage may help lower prescription drug costs and help protect against higher costs in the future. It can give you greater access to drugs that you can use to prevent complications of diseases and stay well. These plans are run by insurance companies and other private companies approved by Medicare. Part D is optional.

For more information visit www.medicare.gov or www.medicarerights.org.

Medicaid
Medicaid is available to low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state’s rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services. Basic benefits are required by the federal government, but states can add additional benefits.

Hospital care, physician visits, prescriptions and home healthcare services are provided to persons who will be disabled for more than a year.

For more information about New York State’s Medicaid Program contact:
www.health.state.ny.us/health_care/medicaid/ ................................... 1-800-541-2831

State Funded Insurance Programs

EPIC (Elderly Pharmaceutical Insurance Coverage)
EPIC is a New York State sponsored prescription plan for senior citizens who need help paying for their prescriptions. Must be age 65 or older. The cost-sharing program applies to low-to-moderate income persons. Enrollees may be elligible for reimbursement of doctor’s fees and portions of co-payments under a program funded by Suffolk County.
(631-853-8200).

For more information on eligibility requirements please visit:
http://www.health.state.ny.us/health_care/epic/ .................................. 1-800-332-3742

Family Health Plus
Family Health Plus is a public health insurance program for adults between the ages of 19 and 64 who do not have health insurance - either on their own or through their employers - but have income or resources too high to qualify for Medicaid. Family Health Plus is available to single adults, couples without children, and parents with limited income who are residents of New York State and are United States citizens or fall under one of many immigration categories.

For more information please visit:
http://www.health.state.ny.us/nysdoh/fhplus/what_is_fhp.htm ........... 1-877-934-7587

Child Health Plus:
Child Health Plus is a New York State health insurance plan for children under the age of 19 who are residents of New York State. Whether a child qualifies for Children’s Medicaid or Child Health Plus depends on gross family income. Children who are not eligible for Medicaid can enroll in Child Health Plus if they don’t already have health insurance and are not eligible for coverage under the public employees’ state health benefits plan.

For more information please visit:
http://www.health.state.ny.us/nysdoh/chplus/what_is_chp.htm .......... 1-800-698-4KIDS

Breast, Cervical, Colorectal and Prostate Cancer Treatment Program:
The Healthcare Workforce Recruitment and Retention Act expanded Medicaid eligibility to certain individuals diagnosed with breast, cervical, colorectal, and prostate cancer or pre-cancerous conditions. Individuals are now eligible for Medicaid benefits for the duration of their cancer treatment.

For more information please visit:
http://www.health.state.ny.us/nysdoh/bcctp/bcctp.htm ....................... 1-866-442-2262

What to do when your coverage is not enough:
If you are finding that your insurance coverage is insufficient, and that your insurance company is unwilling to reimburse claims, there are several organizations and programs that will help you advocate your cause.

Health Insurance Assistance Service
Aids cancer patients who have lost or are in danger of losing their health care coverage, along with identifying policy solutions to help others in similar situations. The service, a joint effort of the ACS and the Georgetown University Health Policy Institute, connects cancer patients who call the ACS cancer information number with health insurance specialists who work to address their needs.
www.cancer.org ................................................................................... 1-800-ACS-2345

Health Insurance Counseling and Assistance Program of New York
The HICAP program assists seniors with health insurance paperwork. Trained volunteers provide the elderly with information and assistance regarding claims and appeals decisions for Medicare, Medicaid, supplemental and long-term care insurance.

Call a volunteer counselor at ............................................................... 631-853-8200
http://www.hiicap.state.ny.us/

The Hill Burton Program
Provides free and reduced cost healthcare at some hospitals with federal funding to help eligible patients obtain treatments they might not be able to afford.

For a list of participating hospitals call: .............................................. 1-800-638-0742

The Patient Advocate Foundation
Employs case managers and attorneys who advocate on behalf of patients that are experiencing a range of insurance issues.

700 Thimble Shoals Blvd., Suite 200
Newport News, VA 23606 ................................................................... 1-800-532-5274
www.patientadvocate.org

The Plan Project, Nassua/Suffolk Law Services
Provides free legal assistance to cancer patients regarding powers of attorney, healthcare proxies, health insurance coverage, Medicaid denials and numerous other legal issues that may arise. Contact Denise Snow, Esq.
1757 Veteran’s Highway
Islandia, NY 11749 .............................................................................. 631-232-2400

Entitlements/Assistance
You are entitled to certain goverment programs known as entitlements that are supported through your tax contributions over the years.

Social Security Administration

Suffolk County Office
526 East Main Street
Riverhead, NY 11901 .......................................................................... 1-800-772-1213
www.ssa.gov

Supplemental Social Security .............................................................. 1-800-772-1213
www.ssa.gov/ssi

Additional Assistance
If you are having trouble paying for your medications, try contacting the manufacturer of the drug. Often, drug companies have financial assistance programs. If you need assistance finding the drug manufacturer or patient assistance programs, please visit www.needymeds.com. Needymeds is an information source similar to the Yellow Pages.

Needymeds does not supply medications or financial assistance but will help you find programs that do.

You may also want to contact the National Council on Aging for information on drug company sponsored discount programs. The NCOA helps older people remain healthy and independent, find jobs, increase access to benefits programs, and discover meaningful ways to continue contributing to society.

www.ncoa.org or www.benefitscheckup.org

If you are in a position to select a better health insurance plan to meet your needs, be sure to refer to The Association of Community Cancer Center’s (ACCC) guidelines for Minimum Standards for Cancer Benefits in Insurance Policies to ensure that your coverage will be sufficient.

www.accc-cancer.org/publications/ ..................................................... 301-984-9496

If you would like to purchase your own insurance you may consider joining an association such as the National Association for the Self-Employed (NASE) to qualify for less expensive group coverage. The process of becoming a “self-employed” worker is fairly simple. Consult the NASE website or call them for more details.

www.nase.org ...................................................................................... 1-800-232-6273

For more information about supplemental insurance, health related news and advocacy for people age 50 and older contact:

The American Association for Retired People
AARP New York Office
780 3rd Avenue, 33rd Floor
New York, NY 10017 .......................................................................... 1-866-227-7442
www.aarp.org/states/ny/

Tip #9 Who Pays for the Next Test or Treatment?
Once someone is diagnosed with cancer, it is very important to try to understand the types of future tests and treatments that are covered by insurance – meaning the insurer pays the costs.

The insurer could be an HMO or the government itself (in the case of Medicaid/Medicare).

Occasionally, there may be a test or treatment that is “cutting edge” and promising – but is very expensive and beyond the scope of the cancer patient’s insurance policy.

In essence, the test or treatment becomes “unaffordable.” At times like that, our healthcare system can seem imperfect.
On the other hand, many Americans are covered by some type of health- care insurance. And most insurance policies certainly pay for basic cancer therapies such as chemotherapy and radiation.

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