Roxanne Nelson

While most people have health insurance, many never pay much attention to it until they experience a serious illness or accident. Needless to say, health insurance can be very confusing, as there is a dizzying array of health plan options, complicated by each state having different rules and regulations.

Many individuals may be unaware of the specifics of their coverage and how to best use their benefits until they take a crash course in an emergency room or doctor’s office. So, while a cancer diagnosis isn’t the best time to figure out the details of what a policy will cover, a clear understanding of the plan can help patients avoid unexpected costs and associated problems.

“The biggest problem I see when people are denied coverage for cancer is the bar for pre-existing conditions,” says Joshua D. Silverman, of the Silverman Law Firm in Richmond, Va., a firm that specializes in medical issues. “My advice for anyone, particularly for people with a diagnosis of cancer or with a family history of cancer, is to make sure they never have a gap in coverage. So long as there is no gap in coverage, a health insurer should not be denying people coverage for pre-existing conditions.”

The Affordable Care Act (ACA) is supposed to solve many of the current problems associated with insurance coverage, such as annual limits and preexisting condition exclusions. “But until it is fully implemented, we really do not know how well it will work,” Silverman says.

Additionally, lifetime limits on coverage will be phased out, so no one should “run out” of insurance. “I don’t think anyone really knows how much these plans will cost,” Silverman says. “The law does limit health insurers’ administrative costs under the 80/20 rule.”

In other words, at least 80 percent of premiums must go towards paying claims and no more than 20 percent of premiums can cover administrative costs. Under the ACA, low-income Americans without coverage will be able to get insurance at low or no cost, typically through Medicaid.

Physicians often work with a number ofinsurance carriers and often do not know thespecifics of coverage.

One risky assumption that individuals often make is that their healthcare provider is knowledgeable about their insurance, when that is likely not the case. “Physicians often work with a number of insurance carriers and often do not know the specifics of coverage,” says Jen Flory, director of the Disability Rights Legal Center in Los Angeles. “They may have certain specialists they work with, for instance, but who may not be in the patient’s insurance network.”

“Patients do need to do their homework and call their carrier,” she says.

Currently, insurance can be broadly divided into coverage that is offered through private plans and those that are offered through federal and state governments.

Private health insurance is available through individual plans, or via groups, such as an employer or association. Health plans provide coverage for preventive care, diagnostic tests, injuries and illnesses, but there are differences in how the plans function. These variations will reflect how services are paid for, the benefits that are included, the degree of flexibility in choosing healthcare providers and the percentage of cost that is covered.

 also known as fee-for-service plans, are often the most expensive choice, but they also provide the greatest flexibility when selecting healthcare providers. Patients can choose any physician or specialist without obtaining prior approval.

 is usually a less-expensive option, but patients must use doctors, hospitals and other practitioners within a restricted network. Co-payments are often lower, but a variety of cost containment processes are enforced and the choice of providers is limited, and unless it is an emergency, the HMO will not cover care given by a practitioner outside of the network. Moreover, a referral from a primary care physician is usually required before patients can seek care from a specialist. HMOs must offer out-of-network coverage when patients do not have adequate access to providers and specialists who can meet their healthcare needs, but prior authorization is necessary.

 while more expensive than HMOs, also offer lower copayments than fee-for-service plans, but with more flexibility than HMOs in terms of selecting a provider. The insurer typically offers the most coverage for staying within the “network” of providers, but patients who choose to go outside the network will incur higher expenses.

 are funds (not subject to federal income tax at the time of deposit) that can be used for medical expenses by individuals who are covered by high-deductible health plans. “Health savings accounts do two things,” Silverman says. “They keep people from being tempted to divert money set aside for medical conditions for other things, and they offer tax advantages.”

 is the nation's health insurance program for people age 65 and older, which consists of several parts:

 covers inpatient costs, such as those incurred in hospitals, nursing homes and hospice;

 provides coverage for healthcare providers, outpatient care, home health care and many preventive services;

 (Medicare Advantage) is a plan offered through approved private companies that includes Parts A and B, and sometimes Part D, but may also offer extra coverage, such as for vision, hearing, dental and health and wellness programs;

 helps lower the cost of prescription drugs in the outpatient setting; and

is a supplemental insurance offered by private companies to fill the “gaps” in Medicare coverage (some Medigap policies may also cover certain benefits that Medicare doesn’t cover).

 run by both the federal and state governments, is health insurance for low-income individuals and those with certain disabilities. The criteria for Medicaid eligibility vary from state to state. Cost sharing also varies, but is generally extremely limited for most program participants.

The Children’s Health Insurance Program,

 like Medicaid, is a program jointly funded through the federal and state governments that provide health coverage to children whose families do not qualify for Medicaid but who are unable to afford private coverage. 

 are programs that provide healthcare coverage for military personnel and their families. TRICARE covers active and retired military personnel and their dependents, survivors and, in some cases, former spouses. CHAMPVA covers veterans and their dependents and is run through the Department of Veterans Affairs (VA). The VA shares the cost of services with eligible beneficiaries. Those who are eligible for TRICARE are not eligible for CHAMPVA.

There are patient assistance programs and,while they don't cover all expenses, they can help.

A cancer diagnosis can be especially difficult for those without insurance. However, there are some options for the uninsured and underinsured that can at least help pay for some care, Flory says. “There are patient assistance programs and, while they don’t cover all expenses, they can help.”

Some are specific to cancer type or geographic area, and some organizations can assist with co-pays and other out-of-pocket expenses for those who have insurance.

One example is CancerCare, which provides assistance for those who cannot afford medication co-payments or who need help with indirect treatment-related expenses. The AVONCares Program for Medically Underserved Women provides financial assistance to low-income and uninsured women, while the Chronic Disease Fund helps patients with chronic illnesses who have insurance but can’t afford their medications.

There are also pharmaceutical assistance programs offered by drug companies and other organizations, Flory says. The Cancer Legal Resource Center provides a telephone assistance line (866-843-2573) for free, confidential information about relevant laws and resources for the caller’s particular situation.

The Health Insurance Marketplace, required by the ACA, provides a way of obtaining insurance or getting a more comprehensive plan. Those who may or may not have access to employer coverage, or who are ineligible for public coverage, might have more choices in these exchanges, which are operated by individual states, by the Department of Health and Human Services (HHS) or in a partnership between a state and the HHS.

Finally, coverage may be available through the Consolidated Omnibus Budget Reconciliation Act (COBRA) and the Health Insurance Portability and Accountability Act (HIPAA). COBRA allows employees to continue receiving group health benefits for a limited time after losing coverage due to job loss, reduction in work hours, etc. HIPAA allows insurance to be purchased after the COBRA period ends, for persons who are not eligible for any public coverage. HIPAA guarantees that insurance can be purchased without pre-existing condition exclusion periods, and plans are available in every state. These plans are expected to end in 2014 as less expensive options become available through the Health Insurance Marketplace.

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Concerns about insurance coverage should be addressed quickly.

Risky Business: Resolve Insurance Concerns Early

Expenses that are not covered by insurance and for which the patient is responsible.

 The amount that an individual must pay out-of-pocket before the insurance coverage kicks in.

 A predetermined, flat fee that the patient pays for covered healthcare services, in addition to the portion covered by insurance.

 The amount the patient pays for a covered service after meeting the deductible, calculated as a percentage of the allowed cost for the service (for example, a 20 percent co-insurance payment for a $100 covered service would be $20).

 A plan that provides extra coverage during a major health event (often with very high deductibles and fairly low premiums).

 An agreed-upon fee that an individual pays for specified coverage of medical costs during a defined period of time.

Know the terms that go into your health insurance plan. 

Speaking of Insurance

Cancer and its treatment can interfere with the ability to work, and some patients may need to utilize long- or short-term disability benefits. However, options may be limited for some patients.

Josie Doresis of Woodbridge, Va., found out too late that she wasn’t eligible for long-term disability coverage from her employer. After receiving a breast cancer diagnosis, she applied for short-term disability during her treatment. But after six months, she was still unable to return to work and needed to take advantage of her employer’s long-term disability benefit.

“But I didn’t realize that it had a ‘no preexisting condition’ clause,” she says.

Many employers offer short-term disability benefits to replace lost income during treatment, but only a handful of states (California, Hawaii, New Jersey, New York and Rhode Island) offer short-term disability programs.

But patients who do not reside in those states or who do not have any type of disability insurance or benefits face a more difficult situation. At the federal level, Social Security provides disability benefits in two ways: through the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program.

But Social Security does not provide for shortterm disability, and eligibility criteria are strict, says Kathleen Walsh, a lawyer based in Virginia who specializes in disability law. “To qualify for SSDI, you have to prove that you will be disabled for 12 months.”

Even if patients don’t know whether they will be disabled for 12 months, they should apply anyway, she says. “You can always withdraw the application and there’s no harm done by applying.”

“If you don’t get approved during the first round of reviews, then you have to appeal,” she says. “And patients should appeal if they feel they are eligible, because by the time they get to the level of the administrative law judge, approximately 62 percent of the cases are approved.”

After 24 months of SSDI benefits, patients become eligible for Medicare. Walsh also points out that receiving disability benefits doesn’t mean that a patient can’t work at all. “You are able to work limited hours, you just can’t be able to return to work full-time,” she says. “So, the extra income is helpful.”

Doresis applied for SSDI but was denied. Before appealing the decision, she went to a Social Security office and spoke with a representative. “I was told to be honest and not to try to sugar-coat the treatment,” she says. “I was told to explain everything.”

Despite supplying all of the information, Doresis’ disability application was still denied. At this point, she retained an attorney who helped her receive approval. For some reason, she says, the Social Security Administration had not received all of the necessary documentation, resulting in the denials.

Although Doresis is happy that she finally received approval, she admits it was an exhausting process. “It really doesn’t seem right to make people who are fighting for the lives jump through so many hoops,” she says. “I also went through all of my resources and had to pay an attorney.”

Patients who haven’t worked or who have health insurance may still receive benefits under the SSI program. To be eligible, patients must have limited assets and income. “They can’t have assets above $2,000 to qualify for that program,” Walsh says. “So, if their spouse is working, they don’t qualify most of the time."

Cancer patients should research their disability options.

Options for Disability

It happens all too often—an insurer receives a claim for healthcare services and denies it, requiring the patient to either pay the cost out of pocket or challenge the denial. To avoid the time and energy involved in dealing with a claim denial, it is important to check with the physician practice or medical center to ensure that all tests and treatments ordered are authorized in advance and that the proper coding and eligibility are checked ahead of time.

But if all seems in order and service is still denied, the first step is to ask the insurer why the claim was denied. It may help to review the health plan and benefits that are covered, and obtain a letter from the physician explaining or justifying the care delivered.

The claim can be re-submitted along with the denial letter, a copy of the physician’s explanation of services and any other supporting documentation. It may be that the service or test in question required different coding, or a billing error needed correction.

It is possible that the claim may still be denied, but patients have the right to appeal, says Jen Flory, director of the Disability Rights Legal Center in Los Angeles. “If it was medically necessary, you are more likely to be successful, but you have the right to appeal regardless.”

The patient should formally appeal the denial to the insurance company, preferably in writing, a process known as an internal appeal. It may be helpful to contact the state insurance regulator to learn about laws regarding health insurance claims or the consumer services division of the specific state’s insurance department or commission.

A second-level internal review can also be requested—an appeal also conducted by the insurance company. At this level, more documentation is usually requested. But if this appeal is also denied, there are still other options.

“If the appeal is denied, then you should file an external appeal, if available,” Flory says. “We found out that a lot of people don’t realize that they have the option of making a formal appeal.”

Individuals who are not connected with the health plan conduct an independent external review. The Affordable Care Act stipulates that health insurance companies in every state must participate in external review processes that meet minimum consumer protection standards. External appeals generally must be filed within 60 days of the date of the insurance company’s final denial of claim, although some states may allow for a longer time period.

The Consumer Assistance Program can help patients file an appeal or a review (visit 

 and search for “consumer assistance program”).

What cancer patients need to know when an insurance claim is denied.

Roxanne Nelson

Risky Business: Resolve Insurance Concerns Early

Speaking of Insurance

Options for Disability

What To Do When Your Claim Is Denied

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