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Cancer and Health Insurance: A Neverending Challenge
Beth Darnley, Sandy Shook, LPN, and Tina Howell of the Patient Advocate Foundation
Obtaining health insurance coverage after a life-threatening diagnosis is very challenging. The health insurance plan options for individuals with pre-existing conditions are available in most states through the State Department of Insurance. The purpose of these programs is to serve those patients with preexisting conditions who have often been denied coverage or have had difficulty finding health insurance coverage in the private market.
Patients should first strive to maintain existing group health coverage through their employer. In 1985, Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA), which requires most employers with 20 or more employees to extend the option to continue group health insurance benefits for specified periods of time. The COBRA law contains provisions that will allow an individual to continue their existing health insurance benefits at their own expense. Those who are covered by governmental plans or church affiliate groups may not be entitled to standard COBRA benefits. Continuation of health insurance benefits is generally offered regardless of reason for termination with the exception of cases of gross misconduct. The plan administrator is required to provide notice of COBRA election rights within 14 days from the date from which the plan administrator received notification of the termination. After notification has been provided to the employee, he or she has 60 days to elect coverage under COBRA. The employee will be required to pay premiums retroactive to the date of termination. The employer is permitted to charge 100% of the premium charged to other plan participants, plus an additional 2% for administrative costs. The employer generally cannot arbitrarily increase an employee's premium after termination; all cost increases are determined by the insurer based on the group underwriting. Increases are most often seen at the yearly renewal of the group plan. It is important to remember that premiums must be paid to the plan administrator before the due date or the employee risks cancellation of coverage. Some states have implemented similar statutes that may expand or conflict with an employer's COBRA obligations. For example, some states require employers with less than 20 employees to provide continuation coverage and some states require continuation coverage for a longer period than required under COBRA.
In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA). This law provides protections for individuals with pre-existing conditions by allowing the application of "creditable coverage" from one group health insurance plan to another. Most health insurance coverage is "creditable coverage." The period of any pre-existing condition exclusion that would apply under a group health plan generally is reduced by the number of days of creditable coverage. For example, a patient was covered by Plan A then changed employers and enrolled in Plan B, which had a 12-month pre-existing condition waiting period. The time in which the patient was covered under Plan A would be "credited" to the pre-existing waiting period of Plan B. This law includes protections for millions of working Americans and their families who have pre-existing medical conditions or who may suffer discrimination based on factors that relate to their health. A pre-existing condition protected by HIPAA is one for which medical advice, care, diagnosis, or treatment was recommended or received within the six months ending on an individual's enrollment date in the plan. It is important to remember that there cannot be a lapse of group health insurance coverage of 63 days or more to benefit from the protections available under this law. The patient should obtain a "certificate of creditable coverage" from his or her prior insurance company. Patients who have elected coverage under COBRA may consider this as creditable coverage as well.
Individuals who cannot afford co continue to pay the premiums to continue their group health insurance benefits under COBRA should apply for State Medicaid benefits or other programs offered in their state. As eligibility varies by state, individuals should contact their local Social Services office. Persons who are 65 years and older or disabled by Social Security (after 24 months of receiving benefits) are eligible for Medicare benefits. Information on Medicare benefits can be obtained through the local Social Security Administration Office or online at www.cms.hhs.gov.
The Patient Advocate Foundation is a national non-profit organization that serves as an active liaison between the patient and his or her insurer, employer and/or creditors to resolve insurance, employment, and/or debt crisis matters relative to a life-threatening or debilitating diagnosis through personalized Case Management services. The Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability. Patients may contact this organization at www.patientadvocate.org or by calling (800) 532-5274.
Resources:
U.S. Department of Labor Publications:
"Health Benefits under the Consolidated Omnibus Reconciliation Act COBRA"
"Compliance Assistance for Group Health Plans-HIPAA and Other Recent Health Care Laws"
Lymphoma Today newsletter is made possible by unrestricted educational grants from the following:
GlaxoSmithKline
Ortho Biotech, Incorporated
Genta Incorporated
IDEC Pharmaceuticals
Lilly Oncology
Novuspharma
