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Understanding Your Healthcare Coverage

If you have health insurance, it's essential that you know what your plan covers and how to maintain your health insurance benefits. This is not only important for newly diagnosed patients but also for survivors who need follow-up visits.

Read your policy carefully to understand the services covered. Find out the portion of medical expenses you'll be responsible for paying. Your expenses may include: 

  • Premiums - the cost to have the health insurance plan. Premium payments are usually made monthly.
  • Deductibles - a fixed amount of money that you must first pay out of your own pocket each year, before the insurance plan will start to pay for your medical expenses.
  • Co-payments - a fixed amount of money that you must pay at the time you receive medical care or prescription drugs. Co-pay amounts aren't applied to the insurance plan deductible amount(s). The co-pay amounts may vary depending on whether you're seeing a specialist (such as a hematologist oncologist) or a primary care provider or if you are taking a brand name drug rather than a generic drug.
  • Co-insurance - the percentage of medical expenses shared by you and the health plan. This is also referred to as a "cost share."  For example, if you have an 80/20 plan, the insurance plan pays 80 percent of your covered medical expenses and you would be responsible for the remaining 20 percent of your medical expenses. The co-insurance amount is in addition to any deductibles and co-payments.

Types of Health Insurance Plans

The following general descriptions may vary from your coverage, so always check your own plan description.

Health Maintenance Organizations

Health maintenance organizations (HMOs) provide plan members with lower costs and coordinated care from a specific list of health care providers, hospitals, and pharmacies. You must use these specific providers in order for your medical care to be covered under the plan. Plan members choose a primary care physician and must get a referral from the primary care physician to see a specialist. 

Preferred Provider Organizations

Preferred provider organizations (PPOs) provide plan members with additional choices in providers, hospitals, and pharmacies. You pay a standard co-pay amount for an office visit. You can choose between a plan or non-plan provider instead of being restricted to designated providers. You can go to a specialist without permission from your primary care physician as long as the specialist is part of your PPO network. A network specialist would be the least expensive choice. If you visit an out-of-network specialist, you may have to pay the entire bill first, then submit a claim for reimbursement. You may have a deductible for out-of-network medical services or you may have to pay the difference between what network doctors charge and what out-of-network doctors charge.

Point-of-Service Plans

Point-of-service (POS) plans blend the features of HMO and PPO plans. Plan participants can choose the type of provider best suited to their needs each time they seek care. This type of plan lets you obtain care from an in-network provider (HMO) and, at the next "point of service," see a provider who is from the larger network (PPO), but pay a little more for your medical expenses.  In a POS plan, you would usually see your chosen primary care physician first for any medical issues. Your physician would refer you to a specialist if you needed one. You could visit a health care provider outside your network and still receive coverage - but substantially less coverage than if you had stayed within the network.

Protecting Patient Rights

Previously, patients could be denied coverage if they had been diagnosed with cancer (pre-existing condition), or because they were diagnosed with cancer at some point in the past (health history). A pre-existing condition is an illness or medical condition that was present before an individual's first day of coverage under a health insurance plan.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides a few protections for patients who have pre-existing conditions.

  1. HIPAA limits the length of time that an insurance company can "look back" into an individual's medical records to determine whether or not they have a pre-existing condition.  The maximum "look back" period is six months. 
  2. In most cases, group health plans can't exclude a pre-existing medical condition from coverage for longer than 12 months.
    If an individual was previously uninsured, but takes a job with an employer offering health coverage, the maximum pre-existing condition exclusion period for medical coverage is 12 months.
  3. If a patient has "creditable" health insurance (such as coverage in a group health plan, COBRA continuation coverage, Medicare, Medicaid, a state high risk plan and a public health plan) for 12 continuous months, with no lapse in coverage of 63 days or more, a new group health plan can't impose the pre-existing condition exclusion. This has helped to ease the issue of "job-lock," whereby people are reluctant to switch to a different job or company for fear of losing their health coverage. In this case, there can't be a waiting period or breaks in dependent coverage for a pre-existing health condition. Insurance carriers issue certificates, called "certificates of creditable coverage," that document the time than an individual has been insured. If the employer imposes a waiting period before the employee is eligible for benefits, and the employee is facing a pre-existing condition exclusion period, then those two time periods run concurrently, rather than consecutively.

Beginning January 1, 2014, patients will no longer be denied coverage for having a pre-existing medical condition or because of their health history, age, or gender.

We're Here to Help

Call The Leukemia & Lymphoma Society (LLS) at (800) 955-4572 to talk with an Information Specialist for help with the challenges of your diagnosis. LLS is committed to providing information, support and guidance to people living with leukemia, Hodgkin or non-Hodgkin lymphoma, myeloma, myelodysplastic syndromes or myeloproliferative diseases. LLS also provides information to healthcare professionals involved in the care of patients with these diseases.

Other Resources

Below are resources and organizations that may be able to help you with your insurance concerns. You can also visit LLS's Resource Center for a list of more organizations.

  • The United States Department of Health & Human Services (HHS).  HHS provides an educational website that gives people a way to find their personal health insurance options, in addition to valuable information about health care reforms. Visit www.HealthCare.gov and www.HealthCare.gov/marketplace.  
  • The United States Department of Labor (DOL). The DOL's Employee Benefits Security Administration (EBSA) regulates health plans offered by most employers and ensures that employees eligible for COBRA get the benefits to which they are entitled. Call (866) 4-USA-DOL for live assistance in English or Spanish. Visit the DOL website for more information.
  • Your state insurance agency. You can contact your state insurance agency to help you understand state laws and programs and get additional information about HIPAA. Get a free health insurance consumer guide for your state from the Foundation for Health Coverage Education. You can also call the Foundation at (800) 234-1317.
  • The Centers for Medicare & Medicaid Services (CMS). CMS runs the Medicare program and works with states on Medicaid programs. Visit the CMS website for more information. Even if you are working you may be eligible for Medicaid. For more information, click here.

Reviewed by Joanna Fawzy Morales, Esq.

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last updated on Tuesday, October 14, 2014
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