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By Kathy Steligo
Note: This is the first of three articles about health insurance for women concerned with breast cancer. The second article covers insurance issues involving hereditary breast cancer, including genetic counseling, genetic testing and prophylactic mastectomy. The final installment offers strategies for successfully handling claims and appealing denials. First, we kick off this series with a broad overview.
Dealing with breast cancer can create emotional and physical burdens. For all too many women, including many who have health care coverage, the burden is also financial.
Health care is the best resource for anyone who becomes ill, especially for someone who develops cancer, because even a short-term illness can be financially devastating. Itâ€™s critical to have a health care policy that provides comprehensive screening for early detection and appropriate treatment. So it pays to assess and understand your coverage, and make sure it will serve you well, before you actually need it.
Having adequate coverage is also important. Whether they know it or not, one in five women under 65 are underinsuredâ€”because many plans limit payments for services and pay only a portion of health care costs, their policies wonâ€™t cover the cost of their cancer treatment. For these women and their families, the portion of breast cancer care for which they are responsible may be financially devastating. Although you may afford premiums, deductibles and co-pays while youâ€™re healthy, out-of-pocket expenses can quickly deplete your financial resources when you need standard breast cancer care. If your medical expenses exceed your policyâ€™s financial cap, you may find yourself maxing out your credit cards, depleting your savings and spending the mortgage payment to pay for your treatment. If the cost of your treatment exceeds your policyâ€™s lifetime cap on benefits, youâ€™ll be left with no health insurance at all.
The ABCs of Health Plans
According to a Kaiser Family Foundation study, nearly two-thirds of American women under age 65 have employer-sponsored health coverage, through their own jobs or their spouses’. Women who are dependents on their spouses’ plans are more likely to lose their insurance if they become divorced or widowed, or if their spouse loses his job. Just six percent of women have individual policies, which can be quite costly. More than nine million low-income women are covered by Medicaid.
Most of us are covered by either a managed care or fee-for-service plan. These include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans. Although there are many variations on these plans, managed care emphasizes preventive services: you choose a primary physician who coordinates and approves your overall care within a network of contracted health professionals and hospitals. With an HMO, you pay premiums and modest co-payments for office visits and prescriptions. PPOs work similarly, although premiums are usually higher. You have greater flexibility to use out-of-network services, but youâ€™ll pay more to do so.
Fee-for-service or indemnity plans offer more flexibilityâ€”youâ€™re not restricted to a network of physicians or hospitalsâ€”but your out-of-pocket costs are higher. In addition to premiums, you must first satisfy an annual deductible before the plan pays a portion of your medical fees (typically 50-80%). Youâ€™re responsible for the remainder.
Choosing the Right Plan
All plans are not alike; nor will all plans provide the coverage you need if you develop breast cancer. Before you sign on the dotted line, read through the plan materials to identify how much youâ€™ll pay, which doctors you can see and what hospitals are available. Never assume a policy covers everything; the risk of being underinsured is too great. Always select coverage only after you clearly understand specifically what will be provided.
If you donâ€™t have employer coverage and canâ€™t afford an individual policy (which can be flexible but costly) there are other options. You may be eligible for group plan rates provided by your union, church or professional organization. Contact your state insurance commissioner to inquire about other alternatives.
Here are six tips for getting the most from your plan:
Should you consider cancer insurance? These policies are only available to those who have not yet been diagnosed. They typically pay for cancer treatment, but not for problems you may encounter because of treatment. If youâ€™re considering a cancer policy, study it carefully; does it offer coverage already provided by your health care plan? If so, many experts say itâ€™s wiser to apply the premiums you would pay for a cancer policy to add more comprehensive care to your existing health insurance.
Coverage for Breast Cancer Services
Within your planâ€™s stated premiums, deductibles and co-pays, your policy should cover the following services related to breast cancer:
Surveillance. All states except Utah now require group health plans to cover all costs associated with routine screening mammograms for women over age 40. [Ed. note: Since this article was originally published, major changes have taken place, including the 2010 Affordable Care Act which ensures that mammograms are covered by insurance in all states.] Your coverage should also include additional diagnostic mammograms, MRIs, ultrasounds, CT scans and other diagnostic tests ordered by your physician.
Treatment. Your plan should cover breast cancer treatments, including lumpectomy, mastectomy, and radiation, if required, and if performed at an approved facility. If your health insurance covers mastectomy, it must also pay for the cost of prostheses, subsequent breast reconstruction (including surgery to the opposite breast for symmetry), and treatment for lymphedema or other complications resulting from mastectomy or reconstructive surgery.
Having a plan with comprehensive prescription drug coverage is essential. Most group plans, including Medicare, offer some type of prescription drug plan and pay for the majority of FDA-approved prescription drugs. If you need chemotherapy, which can be quite expensive and last for months, costs can vary, depending on the type of drugs used, how long you need them and where you receive them. If youâ€™re responsible for a large percentage of the retail cost of each medicine or your plan limits the amount it will pay for medication during a year, you may want to consider a supplemental prescription drug plan.
Second opinions. Itâ€™s always wise to get a second opinion regarding treatment, especially when surgery is involved. Most plans cover the cost of a second opinion. Medicare even pays for a third opinion if the first and second opinions are different.
Alternative and experimental treatments. Increasingly, health plans are providing coverage for acupuncture, massage and other alternative treatments if your doctor recommends them. Insurers frequently deny coverage, however, for drugs or treatments they consider experimental. This may include treatments that have been used successfully but are not yet deemed standard by your insurance company.
Advanced care issues. If you have advanced breast cancer, youâ€™ll need additional services, which will likely be covered to varying degrees depending on the terms of your policy. Most policies will cover a bone marrow transplant, for example, if your physician approves it as a medical necessity. Some policies, however, do not pay for the various screening tests associated with the transplant. If you are unable to care for yourself, many health care plans pay a portion or all of the cost for in-home health care and hospice.
When Youâ€™re Unable to Work or Leave Your Job
If youâ€™re unable to work during treatment, The Family and Medical Leave Act protects your job and health care benefits during 12 weeks of unpaid leave (it also applies if you need to care for a seriously ill parent, spouse or child). You must have worked for the employer an average of 24 hours or more per week for at least a year.
You may be eligible for short-term (six months or less) and/or long-term disability benefits from your employer or your own individual disability insurance policy, if you have one. Social Security Disability Income or your stateâ€™s Supplemental Security Income may also be available if you meet the strict low-income criteria.
Long-term insurance plans provide coverage when you need care at home, in a nursing home or other care facility. Premiums depend upon your age and health; generally, you must be in good health to purchase a long-term policy. Medicare and Medicaid also provide limited long-term care costs.
Two important federal laws protect your right to continue your employer-provided group health plan if you lose or change your job.
If your previous employer had 20 or more employees, The Consolidated Omnibus Budget Reconciliation Act (COBRA) lets you stay on that employerâ€™s health plan for up to 18 months after leaving your job, if you pay the entire premium. If youâ€™re ineligible for COBRA, you may be able to convert your group coverage to an individual plan.
If you have breast cancer, The Health Insurance Portability and Accountability Act (HIPAA) guarantees your right to health insurance when you change jobs. HIPAA prohibits your new employerâ€™s group plan from denying you coverage because of your pre-existing condition. Although a new insurer may ordinarily withhold medical coverage for up to a year for a pre-existing condition, they must cover you as soon as youâ€™re enrolled if youâ€™ve had uninterrupted medical coverage for the previous 12 months.
Help for the Uninsured
If you find yourself without insurance and unable to pay for the cost of routine breast cancer surveillance or treatment, many programs and resources are available to help you receive the care you need. The National Cancer Institute (www.cancer.gov) lists government and non-profit programs to assist women who donâ€™t have health care and canâ€™t afford routine screening or treatment.
Many cancer centers and hospitals set aside funds for women who canâ€™t otherwise afford care. Contact your hospital financial manager, caseworker or outreach counselor. Make them aware of your financial situation; ask about making payment arrangements or inquire about special programs they have in place to provide services to uninsured women. Local and national breast cancer organizations can help too. Visit www.cancercare.org for a list of organizations that help breast cancer patients pay for health care. Your local American Cancer Society can also direct you to other potentially helpful resources in your area.
Uninsured women can get free mammograms through the National Breast and Cervical Cancer Early Detection Program. (Find a contact in your state by visiting http://www.cdc.gov/cancer/nbccedp/ If you receive a mammogram under this program and youâ€™re subsequently diagnosed with breast cancer, youâ€™ll receive treatment through Medicaid.)
If you canâ€™t afford prescribed medications, ask your doctor if he can provide free samples or help you apply for a drug assistance program. Contact the Partnership for Prescription Assistance (888-477-2669 or www.pparx.org) for information about patient assistance programs, including many offered by pharmaceutical companies.
Next article in this series: Insurance Issues when Breast Cancer is Hereditary.
Freelance business and health writer Kathy Steligo has more than a nodding acquaintance with breast cancer. She’s undergone bilateral reconstruction twice, once with expanders and saline implants, once with GAP natural tissue flap. She is the author of The Breast Reconstruction Guidebook.