Insurance Options for Cancer Survivors

1. Insurance Options for Cancer Survivors Phil Kelly State Health Insurance Benefits Advisors (SHIBA) in coordination with Cancer Lifeline

2. As a melanoma survivor you often wonder what options you have when it comes to health insurance.

3. I had health insurance the first time I was diagnosed, but what if I have a re-occurrence, will my health insurance cover it a second time? • The last time was very expensive and I’m close to my lifetime maximum. Now what? • I’ve just been diagnosed, will my insurance cover all of the costs? • I am 65 years old and on limited income. my insurance costs are too expensive.

4. Can I ever change jobs or am I locked • in just to have health insurance? • Is there any help to pay for • treatment? • I am exhausted after 6 months of treatment. My doctor says it’s going to be a minimum of another 9 months of treatment. I don’t know if I can do this but I have used all of my vacation/sick time and my insurance comes with my job. • I have insurance, but I am going to be layed off in June. Now what?

5. The American Cancer Society found in 2008, approximately 684,850 new cases of cancer were diagnosed in people under the age of 65 in the United States. • Prior to the recession, 70% of these folks were estimated to have employer sponsored health insurance. This number has been drastically reduced • 1 One study estimated that the majority of cancer patients under the age of 65—70 percent—have private health insurance.Nearly 4 out of 5 people (79%) in families who spend more than 25% of their pre-tax income on health care costs are insured.

6. Across the United States, in 2006, twice as many people died from lack of health insurance than died from homicide Family USA – March 2008 • Cancer treatment is very expensive sometimes one treatment can exceed $20K • Cancer survivors need long-term treatment and monitoring • Cancer survivors have the most difficulty navigating the health insurance system.

7. Do you have health insurance? • First question asked when you check into a hospital, doctor’s office, lab, radiation or infusion center.

8. You may have insurance through your employer or association • You may have private insurance that you pay for totally on your own. • You may have health insurance with a high deductible or co-pays that you can’t afford = you are “under insured”. • You may have insurance through a federal or state program • You may not have insurance at all

9. What are the Health Insurance options? • Employers (non-self-funded and self-funded plans). • Other group plans (via associations, organizations, etc.). • Commercial Insurers sell plans to individuals. • Government sponsors plans (e.g. High Risk Pools, Medicaid, Breast and Cervical Health programs, COPES, Medicare, Veterans Administration, Children’s Health Programs, etc.).

10. This presentation is a quick overview of what health insurance options exist today…here and now. It isn’t meant to endorse one provider over another or suggest one plan is better. This is solely prepared to give you information and suggest you might have some options. • As you all know, things will change in the coming months to years with the new health care reform. At this point, we don’t have all of the information, but at the end I will share with you what we do know. Disclaimer………

11. Employer-Sponsored Insurance(Self-Funded Plans) • These plans include large companies who are self insured, have an insurance administrator, may be a union trust under a union contract, government plans (Cities, Counties or States) possibly some church plans. • These plans write their own rules. May or may not require a “health screening or health questionnaire.” • These plans can provide excellent or more limited coverage. • Each state has an Insurance Commissioner who does NOT have jurisdiction over self-funded plans. If you have a complaint with a self-funded plan, call your state’s Department of Labor. • If you have had insurance coverage before for over 18 months before enrolling in the new plan, then you usually will not have a pre-existing condition waiting period.

12. Employer-Sponsored Insurance (not Self-Funded plans) • Often are the “Cadillac” of plans available. • Generally, you do NOT have to complete a “health screen or questionnaire.” • Generally, they do NOT reject you based on health status. • If you have had previous coverage you may or may not have a pre-existing condition waiting period. They are getting a little more “choosey these days!

13. Employer Plans • Usually administered by your Human Resources (HR) department • If you have a complaint or concern, you should start here. • COBRA

14. Many Employer-Sponsored Plans Offer COBRA When Your Employment Ends… • COBRA provides insurance to employees (and families) when their employment ends. • Companies with 20 or more employees who offer non-self-funded insurance must by Federal law offer COBRA. • Some self-funded plans offer continuation of insurance, like COBRA. • Federal employees are offered something similar

15. Who Qualifies? • An employee who has had a “qualifying event” • A spouse • Dependent Children • You become eligible to continue coverage if you are enrolled in your company’s plan, there is a qualifying event AND it will cause you to lose your health coverage.

16. What is a Qualifying Event? • For an employee: • You either quit or were terminated for reasons other than gross misconduct OR your number of hours of employment were reduced

17. Qualifying Events for Spouses: • Voluntary or involuntary termination for reasons other than gross misconduct • Reduced work hours • Covered employee becomes eligible for Medicare • Divorce or legal separation of the covered employee • Death of the covered employee

18. Qualifying events for Dependent Children: • Loss of dependent status under the plan (usually due to age) • Voluntary or involuntary termination of employees employment for reasons other than gross misconduct. • Employee reduce hours • Covered employee becomes eligible for Medicare • Divorce or separation of covered employee • Death of covered employee

19. plan administrator will notify you with 14 days of a qualifying event. • plan administrator will notify you with 14 days of a qualifying event. • You have 60 days to continue your health Continue COBRA… • Your employer or plan administrator will notify you within 14 days of a qualifying event. • You have 63 days to continue your health insurance through COBRA and have 45 days after saying YES to pay the initial premium.

20. more on COBRA… • COBRA lasts for 18 months. • It can be extended if you become disabled under Social Security Disability. • You are then covered for an additional 18 months (your family members qualify for an additional 11 months)

21. COBRA is EXPENSIVE! • Yep, it is, but it is usually cheaper than individual insurance premiums and cheaper than paying for cancer treatment out of pocket! • You are paying group rates and an additional 2% for administrative costs. Qualified beneficiaries who receive the additional 11 months of coverage may pay up to 150% of the plan’s total cost. • You MUST pay the premium on the first day of the period coverage or you could be DROPPED.

22. Beyond COBRA • In many states, once you have completed your 18 months of COBRA, you can apply to purchase an individual health insurance plan and not be required to take a health screen or health questionnaire. • This is NOT guaranteed if you do not complete the 18 months of COBRA.

23. Insurance Offered by Professional Organizations/Associations • Insurance can be offered to members of a particular industry, professional group, business association, religious or fraternal organizations. • People who are self-employed and have at least one employee may be able to join an association/organization to get insurance, or may be eligible for a small group plan. • For folks who do not have health insurance I often ask if they COULD join an association for group buying power.

24. Commercial Plans Sold to Individuals (not via employer or membership in an association/organization) • To qualify for these plans, you usually have to complete a health screening questionnaire. Many fail it (and are not eligible to purchase the plan) unless they are young (with limited history of medical problems). • Most of these plans have a waiting period for pre-existing conditions (medical conditions for which you were treated or for which a prudent layperson would have gotten treatment).

25. High Risk Pools • Offered in 35 states for people who are considered “medically uninsurable”. • You have to be turned down by an individual plan • It is very expensive even though it is subsidized by the state government • Some states limit the number of members with pre-existing conditions, limit the maximum cap on annual benefits and have a max on lifetime benefits • It maybe expensive but the only option for some cancer patients • Washington State Health Insurance Pool (WSHIP.gov)

26. Medicaid • Provides health insurance to very specific groups - VERY complicated system. • low-income children, parents, pregnant women, people with disabilities and the elderly • If you are considered a disabled cancer patient (by Social Security Disability) and are low income you may qualify for Medicaid. • Benefits are determined based on income and assets • If you do not have insurance and are low income, you should apply. • If your children do not have health coverage, there is generally programs that will cover them (APPLE) • This is important b/c you DON’T need ONE MORE medical bill when you are dealing with cancer.

27. In addition… • If you are diagnosed with Breast Cancer and age 40-64, you should check into the Breast and Cervical Health Program in your state. This allows women who are “around” the 200% of FPL or below to have all of their medical covered at 100%. This is a “fast-track” on to Medicaid. • They also do cervical and colon screening. • Phone =1-800-756-5437

28. Social Security Disability • If your doctor is telling you that you will be off work for more than 12 month, you should apply for SSDI. • Make sure the medical records reflect this statement. • Apply online. Clock is ticking as soon as you apply • Compassionate Allowances • Fast Track • Metastatic, stage 4 cancers

29. Social Security Disability • Compassionate Allowances • If you are living with metastatic cancer, it is inoperable or unresectable, you will probably qualify for a compassionate allowance which is a fast tract to SSDI. • Can take as little as 3 weeks but often more like 3 months. • Need to have worked for 10 years (have 40 quarters) • In 2 years you are eligible for Medicare

30. The 1989 Legislature enacted RCW 70.170.060, which prohibits any Washington hospital from denying access to emergency care based on inability to pay, or adopting admission policies which significantly reduce charity care.

31. What is Charity Care? • Charity care is for low income people and eligibility is determined by your monthly income and the number of people in your family • Charity care applies to “appropriate hospital-based medical services,” but not to services provided by non-hospital staff. • It covers services within the hospital. It does not cover physicians services during surgery or outside of the hospital.

32. What states have Charity Care or similar programs? • Florida - New Hampshire - Utah • New Jersey - Virginia - Texas • Indiana - Washington - Georgia • Maine - New Mexico - Idaho • California - Indiana • Minnesota - New Hampshire • Rhode Island - W. Virginia • Massachusetts • Pennsylvania -Oregon

33. How do I qualify for Charity Care? • Income and Family Size • Income is based on the Federal Poverty levels that change each April. It looks at the number of people in your household and the total household income. Usually you can expect a lot of help if you are at 100% FPL ($22,050 for a family of 4) • 101% - 200%(44,100 for family of 4) FPL –eligible for some discount • Hospital must develop sliding fee schedule. • Consider your income at time of service vs. time of bill • You can apply for Charity Care at anytime. • You become unemployed after your hospital treatment and now can apply for Charity Care. • Assets may be taken into account.

34. How to I apply for Charity Care? • Hospitals provide notice of Charity Care or similar programs • Don’t be afraid to ask! • “ I want to be responsible for my bill, but I can’t afford to pay it. What kind of help does your hospital have for low income patients?” • Don’t let not having insurance prevent you from going to a public or non profit hospital. • Ask for the ONCOLOGY SOCIAL WORKER, PATIENT NAVIGATOR or PATIENT ADVOCATE. Tell them you need HELP!

35. A few more things about Charity Care • If you have Medicare or Medicaid, you need to use their benefits BEFORE Charity Care will start. Same if you are “under insured”. • You can apply for Charity Care at any time, but generally not after your bill is turned over to collections. • If you are not eligible for Charity Care, ask if you can make payments, NEVER miss a payment! • Don’t be afraid to send even $20 toward your bill. If the provider cashes the check, they have now entered into an enforceable contract with you. As long as you pay, they can’t turn you over to collections.

36. Veteran’s Administration • If you served in in the military dating back to WWI to date you may qualify for medical through the VA. • Benefits are determine by when you served and may include: medical, dental, pharmacy, nursing home. • This is in inexpensive way to fill Rx. • Contact your local VA office and have your discharge papers available. • Plan ahead…you may need a nursing home down the road.

37. Medicare • Medicare primarily provides coverage to those ages 65 and older • Individuals under age 65 who are receiving Social Security Disability Insurance (SSDI) can be covered by Medicare two years after they begin receiving SSDI payments. • Part A, Part B and Part D or a Medicare Advantage Plan

38. Medicare Part A… • The “hospital part” of Medicare. Covers when you are in the hospital, skilled nursing, home health, hospice and blood while in the hospital • Your out-of-pocket is $1,100 (every 61 days) when you check in the hospital unless you have a supplemental policy. It covers 20 days of skilled nursing, 100% of home health and hospice and all but 3 pints of blood. • This out-of-pocket

39. Medicare Part B • Cost is $96.40 per month for people earning less that $85,000. Otherwise =$110/mo • You pay a $155 deductible first • Medicare covers 80% of approved amount for doctor and durable equipment • Medicare covers 100% of approved lab, home health and blood (after 3rd pint)

40. Medicare supplements –AKA as Medigaps • Medigap plans are private health insurance policies that provide you with a way to pay for the gaps in coverage left by Medicare. • Many, many different options and are determine by states and counties. • There are different plans based on need. • Most important thing to remember: All Medigaps in each category provide the same benefits regardless of price. SHIBA can help you choose which plan is right for you.

41. Medicare Part D… • The prescription part of Medicare. • Every state offers different plans 1576 nationwide • Costs range from $8.80-$134.80 and Part D covers • You pay a portion of your Rx costs up to $2,830 then you reach the “donut hole” and are 100% responsible for cost until you’ve paid $6,154, then Medicare cover 95%.

42. Medicare Advantage Plans • The Medicare Advantage (MA) plan pays for all medically necessary care covered by Original Medicare. • The MA plan also may include prescription drug (Part D) coverage, and added benefits, such as eye and hearing exams, dental care, foot care, yearly routine exams, and wellness classes.

43. Medicare Extra Help • WA State offers extra help to meet the costs of Part B premiums. • There is a federal program to help meet the costs of Part D premiums and co-pays. • State Health Insurance Benefits Advisors (SHIBA) can help you look at insurance options.

44. Catastrophic or high deductible insurance • While it may be less expensive, it is NOT recognized as insurance and you will have to take a health questionnaire if you are changing plans.

45. New Health Care Reform – This Year • Kids will be able to stay on their parents insurance until age 26 • Seniors will get a $250 rebate to help fill the "doughnut hole" in Medicare prescription drug coverage • Insurers will be barred from imposing exclusions on children with pre-existing conditions. • Insurers will not be able to rescind policies to avoid paying medical bills when a person becomes ill. • • Lifetime limits on benefits and restrictive annual limits will be prohibited.

46. Cont . Health Care Reform -year one • New plans must provide coverage for preventive services without co-pays. All plans must comply by 2018. • • A temporary reinsurance program will help offset costs of coverage for companies that provide early retiree health benefits for those ages 55 to 64. • Businesses with fewer than 50 employees will get tax credits covering 35 percent of their health care premiums, increasing to 50 percent by 2014.

47. Health Reform 2011 • Medicare will provide free annual wellness visits and personalized prevention plans. New plans will be required to cover preventive services with no co-pay. • A 50 percent discount will be provided on brand-name drugs for Prescription Drug Plan or Medicare Advantage enrollees.

48. So that back those questions…

49. I had health insurance the first time I was diagnosed, but what if I have a re-occurrence, will my health insurance cover it a second time? Assuming you’ve had this insurance for 9 months, yes it will. • The last time was very expensive and I’m close to my lifetime maximum. Now what? Look at WSHIP.org for options or look at another policy with a higher lifetime max. • I’ve just been diagnosed, will my insurance cover all of the costs? This really is based on what type of coverage you have. Check with the provider.

50. Do I have to stay in this job for the rest of my life just so I can have insurance? • If you have 18 months of recognized , you should NOT have to take a health questionnaire so can transfer to another insurance company. • When you apply for a new job, you DO NOT have to tell them that you have had cancer until you are hired.