Expert Interview With Joanna Fawzy Morales, Esq: Navigating Health Insurance

Many people do not understand their medical insurance plans. An important role of oncology nurse navigation is to help patients make treatment decisions based on their circumstances, including type of cancer, stage, treatment options, and importantly, their health insurance coverage and financial factors.

During the 2020 ONA Virtual Navigation Summit, Joanna Fawzy Morales, Esq, of Triage Cancer kicked off the meeting with a presentation entitled “Navigating Health Insurance.”

In this installment of the ONA Interview, we present Ms Morales’ responses to attendee-submitted questions collected during the session.

Attendee: I have a lot of patients who have the affordable health insurance. Their premium may be low but the deductible is so high they can never afford it. The catch is they have insurance so they can get assistance, but no one helps with deductibles and co-insurance. Do you have any insights on how we can navigate patients in these circumstances?

Ms Morales: A limited number of organizations do provide assistance with premiums, co-payments, deductibles, and out-of-pocket maximums. But patients should also think creatively about financial assistance. If they are able to get some help with their utility payments, then they could use that money to pay their out-of-pocket costs.

When a person has the opportunity to make changes to their health insurance coverage during open enrollment or a special enrollment period, that is the time that they should be looking at all of their options. Do the math to pick a health insurance plan with the lowest overall cost for the year, not a plan with just a low monthly premium. Our animated video “How to Pick a Health Insurance Plan” talks about how to do that, and this longer program, “Financial Literacy Full Program,” talks about how to manage costs of care in more detail.

Attendee: Why do pharmaceutical companies offer assistance to people with commercial insurance but not to people with Medicare?

Ms Morales: Unfortunately, that is a federal rule. But, it is an excellent advocacy opportunity. Talk to your members of Congress about how this impacts patients on a daily basis.

Attendee: Are Triage Cancer events open to patients and families as well?

Ms Morales: Yes! Triage Cancer Conferences and Triage Cancer Webinars are open to everyone. We do have a specific training course for health care professionals: Insurance & Finance Intensive.

Attendee: What options are available for patients who continue to work beyond when they become Medicare-eligible?

Ms Morales: Patients who are still working and have employer-sponsored health insurance when they become eligible for Medicare have some options. The employer plan usually requires them to pick up Medicare Part A, because for most people, it is premium-free. Then they can decide if they want to pick up Part B and/or Part D. If they decide not to, when they lose their employer-sponsored coverage, they will be eligible for a special enrollment period to pick up additional coverage under Medicare without facing any penalties.

For details about Medicare, we have a webinar, “Understanding Medicare,” and an extended quick guide, “Quick Guide to Health Insurance: Medicare, as well as other Medicare resources.

Attendee: I work for a for-profit organization and getting financial assistance for some of our patients is difficult because they don’t qualify for Medicaid or Medicare, nor can they afford private insurance. How can oncology nurse navigators help patients who have a limited income but do not qualify for low-income services?

Ms Morales: There are very limited options for health insurance when a patient does not qualify for Medicare or Medicaid in their state and cannot afford private coverage. Financial assistance programs would be an option to help them cover their premiums. But if they have a low income, they may qualify for financial assistance to buy a plan in the Marketplace.

We have a list of financial assistance resources in our Cancer Finances module and our COVID-19 module, as well as a toolkit.

Attendee: Why don’t insurance plans have a checklist of what is covered? Does such a resource exist?

Ms Morales: Unfortunately, most plans do not have a list of everything they cover, but most do have a list of things they specifically exclude. For example, many plans exclude wigs or cosmetic surgery.

Attendee: What are the best websites or agencies to direct patients to for this information to help them make an informed insurance decision?

Ms Morales: Other than Triage Cancer resources, consider what your patient’s information needs are.

If your patient is trying to navigate Medicare, the Senior Health Insurance Assistance Program (SHIP) is a federal program that is available at the county level. Local SHIP offices can be found at https://TriageCancer.org/StateResources.

If your patient is trying to navigate Marketplace options, the Marketplace has local assisters who are trained to help people. They are not insurance brokers and are impartial.

Attendee: Is there a waiting period for Medicaid to pick up COBRA payments once the patient has opted for COBRA?

Ms Morales: The details about how a state handles their Health Insurance Premium Payment Program vary greatly. I recommend contacting your state Medicaid agency about these details. You can find information here.

Attendee: What is the best way to direct our patients to Triage Cancer services? Does our cancer center need to “partner” with you if I’m handing out the link?

Ms Morales: The best way to connect patients to Triage Cancer is to send them to our website (https://TriageCancer.org) to take a look at the resources we have. If they still have questions, they can email us at [email protected] or call us at 424-258-4628.

Attendee: What tips would you give to a patient who is considering enrolling in a clinical trial? Are there strategies you would recommend if their insurance doesn’t cover any out-of-state routine care?

Ms Morales: Triage Cancer has a number of resources on what to consider when thinking about participating in a clinical trial, available on our Cancer Clinical Trials page.

If patients want to participate in an out-of-state clinical trial, where the providers are out of their health insurance plan’s network, they need to talk with their health care team about ways to manage care. An external appeal might be an option. The trial might also be the type where someone could receive care locally, within their network.

Attendee: How is the 60-day window following loss of employer-sponsored insurance triggered?

Ms Morales: The 60-day window for either COBRA or the Marketplace special enrollment typically begins when the employer-sponsored coverage ends. Triage Cancer has a new quick guide and an animated video that provide information on options when someone loses employer-sponsored coverage.

Attendee: Is Medicare going to get rid of the donut hole?

Ms Morales: The Affordable Care Act did close the donut hole completely in 2020. Unfortunately, if the ACA is struck down, that will also have an impact on Medicare coverage of prescription drugs.

Attendee: I recently spoke with 2 patients who need to start chemotherapy treatment. They have Medicare Parts A and B, but do not have a Part D prescription coverage plan or any other prescription insurance. The patients cannot afford the out-of-pocket costs of approximately $17,000 a month. The pharmacist suggested the patient attempt to obtain the medication directly from the manufacturer. A financial advocate is assisting with this (I’m not exactly sure how or if this will work, we will know in 7 to 10 days). I suggested the patients select Medicare Part D during open enrollment so they are covered for 2021. What other options would these patients have in the meantime?

Ms Morales: Without having all the details, engaging the pharmaceutical assistance program is a good option. People who do not accept Parts B and D when they are first eligible for Medicare will not only pay lifetime penalties on their premiums, but also cannot sign up for that additional coverage until the General Enrollment Period. Visit the official US Government site for Medicare for more information.

Attendee: Can you get a Marketplace plan if your employer offers insurance?

Ms Morales: Yes, you can get a Marketplace plan even if your employer offers health insurance. However, you might not qualify for the financial assistance to purchase a health insurance plan in the Marketplace, unless your employer’s plan is unaffordable or inadequate (less than a 60% cost-share).

Attendee: Are Medicare Advantage plans required to provide preventive health services that are on the list of services with no co-pay?

Ms Morales: Medicare Advantage plans are required to provide the same coverage under Medicare Parts A and B, including preventive services. Some details are available in this booklet, Your Guide to Medicare Preventive Services.