Understanding Your Healthcare Coverage
If you have health insurance, it's essential that you know what your plan covers and how to protect your 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 health and medical services covered. Find out the portion of medical expenses you'll be responsible for paying. Your expenses may include:
- Premiums - the cost of participating in the plan. Premium payments are usually made monthly.
- Deductibles - a fixed amount of money that you must meet or pay each year before the insurance carrier will cover your medical expenses.
- Co-payments - a set dollar amount you pay at the time of service for certain medical services and prescription drugs. Co-pay amounts aren't applied against the insurance plan deductible amount(s). The co-pay amount may vary depending on whether you're seeing a specialist (such as a hematologist oncologist) or a primary care provider.
- Coinsurance - the percentage of medical expenses shared by you and the health plan. For example, for some types of plans, the insurer pays 80 percent of covered expenses and the remaining 20 percent of the medical charges would be your responsibility. This cost is in addition to any deductibles and co-payments. Coinsurance may apply to hospital services, certain laboratory tests and, for managed care plans, instances when you receive medical care from a health provider outside of your plan's network.
- Lifetime maximum or "cap" - the maximum benefits that will be paid for each individual enrolled in the plan during your lifetime. Some plans, such as health maintenance organizations (HMOs), limit your choice of providers to those within the plan's approved network.
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 reduced costs and little paperwork for medical services from specific doctors, hospitals and clinics. You must use these specific providers in order for medical services 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 reduced costs. 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 (POS) plans blend the features of HMO and PPO plans. Plan participants can choose the type of provider network best suited to their needs each time they seek care. This type of plan lets you obtain care from a network provider for one type of care and, at the next "point of service," see a provider who has contracted with the POS plan to provide services at a discount. 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 licensed provider outside your network and still receive coverage - but substantially less coverage than if you had stayed within the network.
Protecting Patient Rights
Patients may be denied coverage for a period if their cancer is considered a pre-existing condition. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides several protections for patients who have pre-existing conditions.
The law defines a pre-existing condition as an illness or condition that was present before an individual's first day of coverage under a group health plan. HIPAA limits these exclusions and bans discrimination against employees and dependents based on their health status.
In most cases, group health plans can't exclude a condition from coverage for longer than 12 months. Here are some possible scenarios:
- If an individual was previously uninsured but takes a job with an employer offering health coverage, the maximum waiting period for medical coverage is 12 months.
- If a patient has "creditable" health insurance (such as coverage in a group health plan, COBRA continuation coverage, Medicare, Medicaid, a state health benefits risk pool and a public health plan) for 12 continuous months, with no lapse in coverage of 63 days or more, a new group or individual health plan can't impose the pre-existing 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 that document prior health coverage periods to individuals when coverage is terminated.
National Cancer Legal Services Network
The National Cancer Legal Services Network (NCLSN) promotes access to healthcare and seeks to increase the availability of legal services for people living with cancer, their families and caregivers. For more information, visit their website.
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.
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 Labor (DOL). DOL regulates health plans offered by many large employers. Call their National Call Center at (866) 4-USA-DOL for live assistance in English or Spanish. The Call Center can help workers and employers with questions about job loss, business closures, pay and leave, workplace injuries, safety and health, pension and health benefits and reemployment rights for reservists. Visit the DOL website for more information.
- Your state insurance commissioner. You can contact your state insurance commissioner to help you understand state laws and programs and direct you to other sources of assistance. 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. CMS also helps regulate individual health insurance in a few states. Visit the CMS website for more information. Even if you are working you may be eligible for Medicaid. For more information, click here.
- The National Coalition for Cancer Survivorship (NCCS). NCCS offers The Cancer Survival Toolbox. The Toolbox, a free set of audiotapes, includes a program on finding ways to pay for care if you have little or no health insurance. You can also listen to the toolbox online or read a transcript.