Navigating Health Insurance for Patients With Cancer

After receiving a cancer diagnosis, many patients may struggle to understand even the most rudimentary parts of their life. Furthermore, even without a cancer diagnosis, many people do not understand the terms used in their health insurance policy, such as the acronyms HMO, PPO, and HSA. In an oral presentation at the 2020 Oncology Nurse Advisor Virtual Navigation Summit, Joanna Fawzy Morales, Esq, a cancer rights attorney and CEO of Triage Cancer, a national, nonprofit organization connecting people to cancer survivorship education, discussed the challenges related to health insurance that patients with cancer may face and what their navigators should know.

Researchers from Duke University investigated the impact of out-of-pocket expenses in 2013, and coined the term “financial toxicity” to describe how out-of-pocket medical expenses can have the same effect on quality of life as treatment-related physical toxicity. Factors that contribute to the financial concerns of patients with cancer include employment changes and life changes, both of which can affect the most significant contributor: health insurance status.

Although the federal mandate to carry health insurance has been lifted, some basic protections are still in effect for patients that may be used to manage financial toxicity associated with oncology care. Insurance companies cannot cancel a policy when a person has cancer; nor can they impose lifetime or annual limits on coverage. Young adults can stay on their parent’s plan until age 26. Preventive care such as immunizations and cancer screening must be fully covered, as well as those services rated A/B by the US Preventive Services Task Force. This also includes mammography for women aged 40 and older, coverage of routine costs while participating in clinical trials, and access to internal and external appeals of coverage denials.

Medicare

As it relates to Medicare, consumers must choose 1 of 2 plans: original Medicare and Medicare Advantage (Part C). Both plans include hospital insurance (Part A) and medical insurance (Part B), as well as optional prescription drug coverage (Part D). With the original plan, patients can also obtain supplement insurance (a Medigap plan). Consumers can enroll or change their plans during open enrollment, which is from October 15 to December 7, 2020. Plans are for the calendar year.

Medicaid

For Medicaid, eligibility criteria include low income (less than 138% of federal poverty level [FPL]) plus low resources plus one of the following: aged, blind, disabled; persons undergoing breast and cervical cancer treatment; minor persons or adults with minor children (Medicaid programs for children are administered as the Children’s Health Insurance Program [CHIP]²); and pregnant women, for up to 6 months after the baby’s birth.

Most states have opted for Medicaid expansion, which adds a separate category for adults with a household income less than 138% of FPL. This category is income-based only, with no asset/resource test. As of July 6, 2020, voters in Missouri and Oklahoma approved a ballot measure to expand Medicaid coverage effective July 1, 2021, and the following 12 states have not expanded their coverage: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. Applications for Medicaid coverage are accepted year round. Plans are administered by the states, therefore navigators should be aware of their state’s Medicaid offices for eligibility criteria and enrollment and renewal processes.

COBRA

COBRA allows patients to keep their employer-sponsored coverage for up 18 months if their employment ends or their hours are reduced, making them ineligible for the employer’s plan. A patient who reaches age 26 (loss of dependent child status) may qualify for COBRA for up to 36 months. Patients who are covered under another person’s employer-sponsored insurance plan are eligible for up to 36 months of COBRA coverage if the employee enrolls in Medicare, patient is granted a divorce or legal separation from the employee, or the employee dies. Premium costs are up to 102% of the applicable employee rate.

However, not all employers are eligible to participate in COBRA. Employers with fewer than 20 employees are exempt from federal COBRA laws, but some states may have mini-COBRA laws. In addition, federal employees and church and church-related organization employees are not covered by COBRA. Federal employees may be eligible for Temporary Continuation of Coverage (TCC).

State-Specific Options

All 50 states and Washington, DC, offer either a state or federal health insurance marketplace, or “exchanges.” Patients and navigators should check to see what their state’s program offers, which can include a cap on out-of-pocket costs, premium tax credits, or cost-sharing subsidies. Open enrollment for 2021 marketplace insurance is November 1 through December 15, 2020; however, it may be longer in some states, and marketplaces are open now in California and Washington, DC. A chart of state-by-state health insurance options is available here.

References

1. Fawzy Morales J. Navigating health insurance. Oral presentation at: 2020 ONA Virtual Navigation Summit; September 12-13, 2020. 2. Medicaid.gov. Children’s Health Insurance Program (CHIP): Eligibility standards. Accessed September 11, 2020. https://www.medicaid.gov/chip/eligibility/index.html