Serious illnesses such as oral, and head and neck cancers present many insurance concerns and challenges. Patients who have little or no insurance worry about how they will pay for treatment. Even the insured confront a maze of health insurance regulations that can vary greatly from state to state. Consequently, laws regulating an insurance company’s right to refuse to insure or pay specific claims vary from state to state.
For patients who have little or no health insurance, The National Coalition for Cancer Survivorship (NCCS) has developed the Cancer Survivors Toolbox
The following excerpts are from the NCCS booklet, What Cancer Survivors Need to Know About Health Insurance
More information by Karen Pollitz, M.P.P., of Georgetown University’s Institute for Health Care Research and Policy.
When cancer strikes, you may start thinking about health insurance in a new light. Chances are, you will use your health insurance more than ever before. You also may have more problems with insurance than ever before. Therefore, it is critical that you know and understand your rights and responsibilities under your health insurance plan.
Types of Health Insurance
It’s important for cancer survivors – like everyone else – to have adequate and dependable health insurance. There are many kinds of policies out there, though not all offer the same protection. It’s best to have comprehensive health coverage that will pay for all your basic health care needs such as hospital and doctor care, lab tests, medical equipment, and prescription drugs. When evaluating a policy to see if it meets your needs, in addition to looking at the premium, you need to consider:
- What services are covered?
- How much will you have to pay for covered services?
- From whom can you get care?
Know Your Rights and Their Limits
You have rights under federal and state laws to help you buy and keep coverage, as well as protection when you use your coverage. But these rights are not comprehensive, and they may vary depending on where you live, what kind of coverage you have or seek, and other factors.
Who Regulates My Coverage
To find out about your rights, it helps to know who regulates your kind of health insurance. States regulate many health insurance plans including many group plans sponsored by small employers and most individual coverage you buy on your own. If you have or are trying to buy coverage under these kinds of plans, it is best to call your state insurance commissioner. The federal government regulates some coverage including most health plans offered by very large employers. In this case, you need to call the United States Department of Labor to find out about your rights. When in doubt, though, your state insurance commissioner is usually a good place to start. Your rights to get and keep private coverage are greatest in group health plans that are usually provided through employers. You tend to have far fewer protections when buying an individual policy on your own.
Your Rights Under Group Coverage Offered by Employers
Employers are not required to offer health benefits to their employees. However, if you are offered group health coverage, you have rights under federal and state law, including.
Your eligibility for coverage under a group health plan cannot depend on how healthy you are now or have been in the past. This means you can’t be refused health benefits under an employer’s health plan simply because you are a cancer survivor.
Special Enrollment Periods
You must be offered a special enrollment period of at least 30 days when you get married, divorced or widowed, have a baby or adopt a child, or lose other health coverage (for example, the coverage that another family member had through his or her employer). If your employer provides family coverage, all of your dependents must be offered this special enrollment opportunity as well.
Coverage for Pre-Existing Conditions
Sometimes group health plans will temporarily exclude coverage for a health condition that you already have when you join. This is called a pre-existing condition exclusion period, or pre-ex, for short. If your group health plan does this, you will have insurance coverage but it will not pay for any care related to your pre-existing condition during the exclusion period. Group health plans cannot impose a pre-ex longer than 12 months, or 18 months if you are a late enrollee. Also, there are limits on what can be subject to a pre-ex. In group health plans, a pre-existing condition is one for which you actually received a diagnosis, treatment, or medical advice in the 6-month period- known as the lookback period- prior to joining the group health plan. In addition, group insurers cannot consider pregnancy or genetic information as a pre-existing condition.
Credit for Prior Coverage
When a group plan imposes a pre-ex, it has to give you credit for other health coverage you may have had in the past. Whenever you leave a health plan, you should be given a certificate as proof of the coverage that you had. To be creditable, your prior coverage must have been continuous, which means it cannot have been interrupted by a lapse of 63 days in a row or longer. Most kinds of health insurance are creditable toward a group health plan pre-ex, including other group plan coverage, individual coverage, state high-risk pool coverage, Medicare, Medicaid, and military health care (CHAMPUS).
COBRA Continuation Coverage
A federal law, known as COBRA, lets you and your family stay covered under your group health plan when you leave your job or in other circumstances. Depending on your situation, you and/or your dependents can remain in the group plan for up to 18 to 36 months. When you take COBRA coverage, you have to pay the entire premium (including the portion the employer used to pay on your behalf.) Your Rights Under Individual Health Coverage
In most states, buying individual coverage can be harder if you are a cancer survivor – especially if it’s been less than five years since your treatment ended. Where not prohibited by law, insurance companies can turn you down, charge you more, or permanently exclude coverage for cancer -though not all companies will do so. The rights you have when buying individual health insurance depend on where you live. State laws regulating individual health insurance vary a lot. Consult your state insurance commissioner for more information.
Sometimes you can get health insurance from the government, instead of from a private employer or insurance company. Usually, you can only get public coverage if you qualify based on your age, your income, or your health status. Medicare and Medicaid are the biggest public programs and are available in every state. In a few states, there are other smaller programs that might be able to help you buy affordable health insurance.