Introduction
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General Categories Of Health Insurance
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Indemnity Plans
Indemnity plans allow you to choose any doctor or hospital when seeking medical care. However, these plans typically have a deductible, which you have to pay before the plan will pay for any medical expenses. Once you have paid the deductible, the health plan will pay a percentage of the medical expenses. Many plans pay about 70% to 80% of the bill. The percentage of a medical bill that the health plan will pay is called co-insurance. The remainder of the bill needs to be paid by you. The amount that you need to pay is called patient liability. Indemnity plans vary greatly and you will need to check the particulars of the plan as it relates to you.
Although many plans require you to pay a co-insurance of 20%, you only have to pay this percentage until you reach your annual out of pocket maximum. If you have an out of pocket maximum of $2000, for example, the insurance plan will pay 100% of your claims after you have paid this amount.
Health Maintenance Organization (HMO) Plans
HMO plans usually contract with a specific list or panel of doctors from which you must choose. As a member of an HMO you will have a primary care doctor who is responsible for your care. If you wish to receive care from a specialist, you must get a referral from your primary care physician. As long as you see doctors within the HMO network, you will only be required to pay a small co-payment per visit. The co-payment generally ranges from $5 to $25. Most other charges are covered by the plan. Thus, there are no deductibles or claims forms as long as the care is received within the plan.
If you want to see a medical provider that is not within the HMO network for a second opinion or for other medical care, you will need a written authorization from the HMO medical group. If you do not get authorization for the visit, the HMO will not cover the costs of the visit. The authorization process can sometimes take up to a week, so plan ahead. If your request to receive a particular treatment or to see a specialist outside of the plan is denied by the HMO, it is worthwhile to appeal the decision. (See section on Appealing Rejections.)
Preferred Provider Organization (PPO) Plans
PPO plans combine some elements of the HMO plan with elements of the indemnity plan. Like the HMO, the PPO plans have contracts with a specific list of medical providers. If you see a doctor that is in the network, the PPO will generally pay 80%-100% of the medical bills after you pay the deductible. If you use providers that are outside of the PPO network, the plan will pay a lower percentage of the bill than if you use a provider within the network. When you receive care outside of the network, the plan will require you to pay a certain amount, called a deductible, before it will cover any of the medical expenses you incur outside of the plan.
Point of Service (POS) Plan
A POS plan is the most versatile type of plan, providing three types of coverage - one that functions like an indemnity plan, another that functions like an HMO, and one that functions like a Preferred Provider Organization plan. As a member of a POS plan, you can move between these different forms of coverage each time you receive care. Each level of coverage is called a tier.
- Tier 1
- functions just like an HMO. If you choose to receive your care through your primary care physician in your HMO, you will only be responsible for a small copay. Your primary care physician can refer you to other specialists within the HMO. There are no deductibles at this level.
- Tier 2
- functions like a PPO. You can self-refer yourself to any provider in the PPO network of physicians. The insurance will pay for a certain percentage of the medical charge. You will be responsible for an annual deductible and for co-insurance payments.
- Tier 3
- functions like an indemnity plan. You can self-refer yourself to a provider of your choice outside the network. The insurance will pay for a lower percentage of the medical charge than in tier 2. You will be responsible for an annual deductible and co-insurance payment that is greater than that of Tier 2.
These are plans in which a company or union insures you with money they have set aside to cover your health claims. Since this type of coverage is less regulated, there is a great deal of variation among the policies. If you are a member of a self-funded plan, thoroughly review your benefits to see what is covered. For most self-insured plans, benefits for pre-existing conditions are severely limited during the first year of coverage.
Extending Your Group Health Insurance
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COBRA
COBRA is a federal law that allows individuals working in firms of 20 or more employees to continue their health insurance benefits for up to 18 months after their employment terminates. During the time that you are covered by COBRA, you are responsible for paying 102% of the total health insurance premium, including the portion of the premium that was paid by your employer. If you cannot afford the monthly payments, you might be able to use the Medi-Cal HIPP program to pay your premiums. (See information on Medi-Cal HIPP.) Once your COBRA benefits expire after 18 months, you can use OBRA to continue your health insurance benefits for an additional 11 months.
OBRA
OBRA is a federal law that allows individuals to extend their COBRA coverage for an additional 11 months. Only individuals who elected to use COBRA because of a Social Security approved disability are eligible for OBRA. During the time that you are covered by OBRA, you are responsible for paying 150% of the total health insurance premium, including the portion of the premium that was paid by your employer. If you are still disabled once your OBRA coverage expires, you will be eligible for Medicare, which provides health coverage for people who have been disabled for 29 months or more.
Getting Insurance With A Pre-Existing Condition
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MRMIP: Major Risk Medical Insurance Program
MRMIP is a state program that provides medical insurance for people who are unable to obtain medical insurance in the open market. If you have a pre-existing condition and have been denied coverage by private insurance companies and are not eligible for Medicare, you may be eligible for MRMIP. The plan offers a wide range of medical providers with assorted plans and offers prescription drug coverage. The annual limit is $75,000 with a lifetime maximum of $750,000. There is an annual deductible of $500 and a co-payment maximum of $2,500 per year. More information can be obtained by calling the California MRMIP phone number at 1-800-289-6574.
Professional Associations or Membership Organizations
If you have a pre-existing condition and are having difficulty obtaining health insurance, you might be able to obtain group health insurance through a professional association. You might already belong to an association or might be able to join one. There are many different associations, including the Bar Association, the Media Alliance, the Actors Association, and the American Medical Association, etc. Once you obtain health coverage through your association, you will have to pay the medical premiums yourself. If you join an association and have a choice of health care plans, keep in mind that indemnity plans and PPO plans often have a waiting period of up to six months before they will cover you for a pre-existing condition. HMO plans are required by law to cover your pre-existing condition immediately.
Health Insurance Plan of California (HIPC)
HIPC offers coverage for people working independently or who work for small businesses. Because this plan pools together a large number of individuals, it offers many of the options previously available only to large businesses. As a HIPC member, you may be eligible to choose from among 22 HMO or POS plans. To obtain more information, call 1-800-255-4472.
Information About Public Benefits
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Medicare
Medicare provides health coverage for people who qualify for social security. Most people become eligible when they reach the age of 65 or if they have been disabled for 29 months (See definition for disability). Medicare covers hospitalization, skilled nursing, home health and hospice care, but requires certain deductibles, premiums and co-payments. If you are receiving outpatient care, Medicare will only cover 80% of allowable outpatient medical services. You are responsible for 20% of the charge, regardless of the cost. Note that Medicare does not cover outpatient prescription drugs unless they are administered in a doctor's office or an outpatient clinic. Because of this many patients choose to enroll in Medicare HMOs or to buy relatively inexpensive private health insurance supplements to reduce their out-of-pocket costs. If you cannot afford to buy private health insurance, You might be able to supplement your Medicare with Medi-Cal. If you would like more information about Medicare, you can contact HICAP (see below).
HICAP - Health Insurance Counseling and Advocacy Program
HICAP provides information to seniors and other people on Medicare. HICAP counselors can help you understand Medicare, compare private Medicare Supplemental plans, review Medicare HMOs, develop a system to organize your doctor and hospital bills, file Medicare and private insurance claims, and prepare Medicare appeals or challenge claim denials. All HICAP services are provided free of charge. To speak to a HICAP counselor, call 1-800-303-4477.
- Medi-Cal
- Anyone who qualifies for Supplemental Security Income (SSI), a federal needs-based income program, will also qualify for Medi-Cal. You should apply for SSI as soon as you can after becoming disabled so as to establish an ``onset date'' and start an application. Medi-Cal provides health coverage for certain individuals with low incomes and resources who qualify for disability. (See Social Security definition of disability.) Medi-Cal will pay health care bills incurred up to three months prior to the application date. To apply for Medi-Cal, visit your local Social Security office or call the Social Security at 1-800-772-1213. You can also obtain information from the Social Security web page at http://www.ssa.gov
If your disability income is above the SSI limits, you may still qualify for Medi-Cal, but with a share of cost. To apply for this form of Medical , you will need to contact the County Medical Office in your area, which is listed under the county department of Human or Social Services.
One of the disadvantages of Medi-Cal is that not all doctors accept new Medi-Cal patients. There may also be certain limitations on treatments and prescription drugs that are covered. If you have private insurance at the time that you become disabled, you may be able to enroll in the Medi-Cal HIPP program (see below), which will help you pay for the continuation of your private insurance while you are on Medi-Cal.
Medi-Cal HIPP: Health Insurance Premium Payment Program
Medi-Cal HIPP will pay the premiums for your private health insurance plan. In order to participate in the Medi-Cal HIPP program, you must be eligible and enrolled in Medi-Cal, but not in any of the Medi-Cal HMO programs or MRMIP (see below). You also must be insured under a private health insurance plan that does not exclude your serious medical condition. If you are eligible, Medical HIPP will allow you to keep your private health insurance while you are on Medi-Cal. Unlike Medi-Cal, Medi-Cal HIPP will not make retroactive payments. To apply for Medi-Cal HIPP, call the Medi-Cal HIPP office at 1-800- 952-5294.
Social Security Definition Of Disability
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A disability is defined as a physical or emotional impairment which is severe enough to keep a person from doing work for a continuous period of one year or which can be expected to result in death. It is possible to apply for disability benefits at any Social Security office by calling 1-800-772-1213.
Employment Discrimination Laws Protecting Cancer Survivors
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The Americans with Disabilities Act and Federal Rehabilitation Act prohibit certain types of job discrimination by employers against people who have or have had cancer.
Reasonable Accommodation
If you are undergoing treatment for cancer or are recovering from cancer, federal law requires an employer to provide you with reasonable accommodation such as a change in work hours or duties. The employer is only required to provide you with reasonable accommodation after you inform the employer of your condition.
Family and Medical Leave Act
The Family and Medical Leave Act require an employer with 50 or more employees to provide up to 12 weeks of unpaid job-protected leave for family members who need time off to address their own serious illness or to care for a seriously ill child, parent or spouse.
Viatical Settlements
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Usually life insurance policies are used to benefit an individual's designated beneficiary when the policy holder dies. Recent laws, however, have made it possible for individuals with a catastrophic or terminal illness to sell their life insurance policy while they are still alive. This process, called viatication, enables individuals with a terminal disease to access a crucial source of money while they are still alive. Many people use the money from the sale of their life insurance policy to get additional treatment or to pay their bills. Companies offering viatication services typically pay between 35% to 85% of the face value of the policy. If you are considering viatication and have a life insurance policy through your work, it is important to make provisions for the continuation of the policy once you stop working so that you have the option of viatication at a later date. Since you will only receive a certain percentage of the face value of your life insurance policy, it is important to use sound judgement when considering this option. Another option is to contact the insurer of your policy to see if the company offers an accelerated benefits program.
Appealing Rejections
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If you or your medical provider is told that a particular procedure is not covered, see if you can appeal the procedure or ask your doctor or hospital to repeat their request for an authorization. In some cases, different people at the same insurance company arrive at different conclusions. It is, therefore, often worthwhile to appeal the case. In a situation in which you think that the insurance company is treating you unjustly, an entry of a lawyer may lead to a quick reversal of the rejection without any need for litigation.
Having Trouble Meeting Your Medical Payments?
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If you are having trouble paying your medical bills, speak to your social worker or to the Practice Manager to see if there is any way to accommodate you. Staff at the Cancer Resource Center and social workers may also be able to refer you to a variety of useful services to help you reduce your financial burden. These services include pharmaceutical companies that provide low cost and free drugs to low income patients, reduced utility rates for low income patients, and coverage for certain transportation services.
Keren Stronach, MPH is the Manager of Ida and Joseph Friend Cancer Resource Center, UCSF/Mt. Zion
Confused About Health Insurance And Benefits? Sign Up For A Benefits Workshop At The Cancer Resource Center, 415-885-3693. Your Health Insurance Can Also Answer Your Questions.
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