Insurance

One of the biggest components of the Affordable Care Act (also known as “Health Care Reform”) was a push towards consumer-friendly access to information. Accordingly, the new health care law created a national website, known as “The Portal” to explain not only how the law has changed the face of health care by expanding coverage options, but how different plans and options function together.

The main page for The Portal is at http://www.healthcare.gov.

Healthcare.gov also allows users to figure out what insurance options they have available to them (available at: http://finder.healthcare.gov/) and, in the context of figuring out which option is best, the website has a section on how to compare providers, (available at: http://www.healthcare.gov/compare/index.html).

We’ll have to wait a little longer for the full law to go into effect, but starting in 2014, the website will let individuals and small businesses compare specific health plans, known as “Exchanges”, against each other—allowing people to “get answers to questions, find out if they are eligible for tax credits for private insurance or health programs like the Children’s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs.” For more information about Health Insurance Exchanges, please go to: http://www.healthcare.gov/law/features/choices/exchanges/
One of the biggest components of the Affordable Care Act (also known as “Health Care Reform”) was a push towards consumer-friendly access to information. Accordingly, the new health care law created a national website, known as “The Portal” to explain not only how the law has changed the face of health care by expanding coverage options, but how different plans and options function together.

The main page for The Portal is at http://www.healthcare.gov.

Healthcare.gov also allows users to figure out what insurance options they have available to them (available at: http://finder.healthcare.gov/) and, in the context of figuring out which option is best, the website has a section on how to compare providers, (available at: http://www.healthcare.gov/compare/index.html).

We’ll have to wait a little longer for the full law to go into effect, but starting in 2014, the website will let individuals and small businesses compare specific health plans, known as “Exchanges”, against each other—allowing people to “get answers to questions, find out if they are eligible for tax credits for private insurance or health programs like the Children’s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs.” For more information about Health Insurance Exchanges, please go to: http://www.healthcare.gov/law/features/choices/exchanges/

Insurance policies are private contracts between insurance companies and those receiving benefits under that policy, so different health insurance policies are ultimately going to contract in and out of different forms of treatment. As a general rule, you can always look for policies that cover more kinds of integrative therapies if those are important to you and your specific course of treatment.

Outside of shopping around for policies that may have more of the types of services you’re looking for, one way to push for movement in this and any other issue area is to pursue some form of legislative advocacy. For integrative therapies, you can speak to your representatives and tell them that these types of treatments should be covered as “essential health benefits” in all plans.

For information on your elected officials go to: http://www.house.gov (to find your U.S. Representative), http://www.senate.gov (to find your U.S. Senators), and http://www.votesmart.org (to find your local elected officials).
Insurance policies are private contracts between insurance companies and those receiving benefits under that policy, so different health insurance policies are ultimately going to contract in and out of different forms of treatment. As a general rule, you can always look for policies that cover more kinds of integrative therapies if those are important to you and your specific course of treatment.

Outside of shopping around for policies that may have more of the types of services you’re looking for, one way to push for movement in this and any other issue area is to pursue some form of legislative advocacy. For integrative therapies, you can speak to your representatives and tell them that these types of treatments should be covered as “essential health benefits” in all plans.

For information on your elected officials go to: http://www.house.gov (to find your U.S. Representative), http://www.senate.gov (to find your U.S. Senators), and http://www.votesmart.org (to find your local elected officials).

Yes we do but at the health care system i go to alot of the Doctors don't know hardly anything about lymphedema. It has been an uphill struggle since diagnoses. I learned alot fast, and been told by Doctor's I was wrong, turns out they were. Have had to file complaints against a few. It's crazy!! Yes we do but at the health care system i go to alot of the Doctors don't know hardly anything about lymphedema. It has been an uphill struggle since diagnoses. I learned alot fast, and been told by Doctor's I was wrong, turns out they were. Have had to file complaints against a few. It's crazy!!

You have to understand your insurance plan before you receive a bill from your physician or other medical professional. Call the customer service phone number on your health insurance card and ask:
1. Is my doctor or other medical professional a network provider? Are they on my plan?
2. If he/she is out of my network, what portion of his/her fees will I have to pay out of pocket?
3. If my medical professional is in network, what is my co-pay?
4. Is the service, procedure or surgery covered by my insurance plan?
5. You can also ask the medical biller at your medical professional's office to help you.
6. You should receive an Explanation of Benefits (EOB) regarding your medical service. This will explain what is covered, what isn't and how much you have to pay.
7. Some physician's office will submit your super bill for you, most will not. If you have your super bill, call your health insurance company and ask the above questions. Then you can send in a copy of your super bill with a copy of your health insurance card (send certified with return receipt requested)
Hope this helps! You have to understand your insurance plan before you receive a bill from your physician or other medical professional. Call the customer service phone number on your health insurance card and ask:
1. Is my doctor or other medical professional a network provider? Are they on my plan?
2. If he/she is out of my network, what portion of his/her fees will I have to pay out of pocket?
3. If my medical professional is in network, what is my co-pay?
4. Is the service, procedure or surgery covered by my insurance plan?
5. You can also ask the medical biller at your medical professional's office to help you.
6. You should receive an Explanation of Benefits (EOB) regarding your medical service. This will explain what is covered, what isn't and how much you have to pay.
7. Some physician's office will submit your super bill for you, most will not. If you have your super bill, call your health insurance company and ask the above questions. Then you can send in a copy of your super bill with a copy of your health insurance card (send certified with return receipt requested)
Hope this helps!

Almost all indsurances cover external breast prostheses post mastectomy. They are usually covered under the DMEPOS (Durable Medical Equipment Prosthetic Orthotic Supplies) portion of a private insurer and may have a separate deductible from general medical treatments. There are usually time and quantity limits and breast prostheses, bras and accessories and these differ depending on the health plan. A prescription is always necessary when billing insurance. Some states require those individuals that fit breast forms and bras to be licensed and/or certified. Medicare covers breast prostheses and bras under some limts with a prescription and when a certified provider is consulted. Yes, insurance usually pays for the cost of a breast prosthesis after mastectomy. You may need a prescription from your physician.

We are going to organize a panel on insurance at our March 1-3, 2012 West Palm Beach conference and hope to really get a national conversation going. Insurance is a state by state issue UNLESS Medicare takes it on. With the costs rising for conventional cancer treatment - sometimes to insane leveles - this may happen.

We need a leader for the issue and petitions started. I have been told that insurance companies fear that supporting healthy behavior could 'cost too much'. But I do not see that myself.

Perhaps if people come to our Facebook page Annnie Appleseed Project (nonprofit) and express their feelings on this, we can take it further. We are going to organize a panel on insurance at our March 1-3, 2012 West Palm Beach conference and hope to really get a national conversation going. Insurance is a state by state issue UNLESS Medicare takes it on. With the costs rising for conventional cancer treatment - sometimes to insane leveles - this may happen.

We need a leader for the issue and petitions started. I have been told that insurance companies fear that supporting healthy behavior could 'cost too much'. But I do not see that myself.

Perhaps if people come to our Facebook page Annnie Appleseed Project (nonprofit) and express their feelings on this, we can take it further.

These women can go to the NLN, which has funding for garments for people who cannot afford them. As to treatment (CDT), I would say they can ask if the treatment center has funding for people who can't afford it. These women can go to the NLN, which has funding for garments for people who cannot afford them. As to treatment (CDT), I would say they can ask if the treatment center has funding for people who can't afford it.

I kept a journal. Whenever I made a call I wrote the date, company, address and phone # then person I spoke with. I write down everything that is said in the conversation, questions and answers, everything. I highlight the company name in a color. Then whenever I have to refer back I look at my list of companies and highlighted colors. If its blue I know to refer back to all blue highlighted conversations, I will then color another company with a different color so and so forth. On the front of folder just keep writing the name of company and highlight it, that is your index so to speak. I certainly could not count on my brain so this helped me tremendously. With making things color coded it also made it quicker and easier to find the previous call. Something that has always helped me is to find out the name of the person that I am speaking with and I always get a reference number for the call. Of course I always laugh out loud when the first thing that you hear (before you spend ten to thirty minutes on hold) is that what you are told verbally is not always correct and that you need to "refer" to your contact.....like you can understand the verbage!!!

Great advice in first two answers. Thanks.

My insurance wouldn't pay either, but Merck had a program to furnish it to patients in those circumstances. Don't think we ever had to buy a single dose - they mailed them to me before each scheduled chemo. Your doc should contact them for you an arrange that. First you need to ask your doc if there is anything that is a generic that's comparable to Emend. The price of Emend may be a function of its place on your Pharmacy plan's Formulary, and, as such may be in a Tiered Plan situation where certain inexpensive drugs are made more accessible, and as the complexity and expense of the drugs go up so may your co-pay. If there is no comparable drug to Emend, and if this is truly the only med to work for you, then you'd get a letter of medical necessity from your doc over to the PBM/Managed Care Org. with a request to keep the patient expense to a minimum. In the interim, I would call the Managed Care Org. and ask to speak to the CEO's office ("I'd like Joe Smithers office please.") Then you explain your situation to the assistant and ask for a remedy as it's an expensive drug. Also, I'd contact your company's HR/Benefits people to see if they can suggest a remedy for you as they took part in purchasing the plan. Use as much emotional leverage as you can here. I wish you luck.

Here is some more information from the American Society of Clinical Oncology that might be helpful: http://www.cancer.net/patient/All+About+Cancer/Managing+the+Cost+of+Cancer+Care/Financial+Resources In our experience medical debt crisis is a large concerns for patients who contact Patient Advocate Foundation. Many cancer patients have inadequate insurance or none at all and due to affordability, pre-existing clauses or a multitude of other reasons find themselves in this situation upon diagnosis. Some of the areas a patient can explore depending on income, asset and qualifiers are to apply for governmental programs such as Medicaid and/or Medicare, obtaining charity care and/or financial assistance through medical facilities, and obtaining necessary medications through prescription assistance programs or other state/national medication assistance programs (www.needymeds.com). Patients can explore clinical trials as a feasible option for access to care as well. It is always important to explore insurance options such as enrolling in plans offered at their own place of employment or their spouses. Children now can remain enrolled or re-enroll in their parents plan up until age 26 under healthcare reform, explore high risk pools or pre-existing health insurance plans (www.pcip.gov) now mandated by healthcare reform in each state, guarantee issues plans, individual/group insurance, and COBRA options. Georgetown University has an excellent website, http://www.healthinsuranceinfo.net that is a state by state consumer guide on how to get and keep health insurance and addresses topics I outlined here.

If the patient is insured is underinsured meaning he/she has health insurance coverage but lacks the financial resources needed to cover out-of-pocket expenses for medical care. Or underinsured when access to medical services is inhibited as the direct result of insurance benefit exclusions the patient can follow the same options as listed above. If they are insured through an employer who offers more than one plan, they should consider switching their benefit plan to a better option come open enrollment or if there has a been a qualifying event. Also there are many co-pay relief programs available such as our own Co-Pay Relief (www.copays.org)that can offer financial relief to qualified patients.

PAF is here to provide support to any patient with cancer who has difficulty accessing care regardless of their insurance status. We can be reached at 800-532-5274.

The breast reconstruction laws ensure insurance companies "cover" reconstruction and symmetry procedures (typically 1 more procedure after the initial reconstruction), but unfortunately this does not mean the patient can't face a nasty financial surprise.

It's very important to check whether your plastic surgeon is in-network for your insurance plan to avoid issues such as "balance billing". Out-of-network physicians can essentially bill the patient for the difference between their fees and the reimbursement by the insurance company. This can mean the patient is responsible for a significant part of the bill which can run into thousands of dollars.

I recommend patients discuss the possibility of balance billing with their surgeons before scheduling their surgery.

Hope that helps.

Dr C
If you are wondering if your insurance will cover the plastic surgery procedures desired to restore your breast shape, size- the answers can be found in your insurance plan benefit booklet. Most large insurance companies consider lumpectomy a "partial mastectomy" and will extend benefits for breast reconstruction procedures. Lets take a look at the policy language from UHC published on their public website - Their policy Breast Reconstruction Following Mastectomy #B-SHO-004 - UHC Medicare Plans states:

Guidelines/Notes:
1. When a member elects breast reconstruction following a medically necessary mastectomy or lumpectomy, coverage is to be provided as determined through consultation between the attending physician and the member, and includes:

a.Reconstructive breast surgery of the affected breast
b.Surgery and reconstruction of the unaffected breast to produce a symmetrical appearance
c.External breast prosthesis
d.Initial breast implant
e.Replacement breast implants when medically necessary
f.Nipple tattoo for reconstructive purposes
g.Tissue expansion
h.Regional tissue transfer
i.Treatment of physical complications resulting from the mastectomy or lumpectomy, including lymphedema. Treatment for lymphedema may include:.................(there's more but this portion makes my point)

_________________________________________________________________________
Any plastic surgeons office who routinely offers reconstruction procedures should pre-determine benefits with your insurance company and be able to explain exactly what is covered and what your out of pocket cost will be once you have decided what type of procedure you would like to have. Know all of your options, go in to the plastic surgeons office with a list of questions and ask them all, they should be more than happy to help.

All the best,

Gail L.

Without specific information on your current health condition, treatment protocol and review of your disability plan, I am not able to tell you if you would qualify for benefits. Each disability plan have their own contract language that dictates benefits offered, when they start and how long and when they continue. Additionally, often the medical support of your treating physician(s) is necessary to support a disability claim. If your treatment and/or side effects are affecting your ability to work, review your plan and discuss going on disability with your provider. File a claim and await a decision. If you do find yourself denied, review the reason why and file an appeal. Patient Advocate Foundation wrote a publication called Your Guide to the Appeal Process available at http://www.patientadvocate.org/index.php?p=489.

Some areas I would request your review are:
1. Does the policy have a waiting period (period of time) before it will allow you to submit a claim?
2. Are there medical requirements you have to meet, i.e, cannot perform your job or ANY job; must be unable to work for at least 6,12 months etc.
3.Do you have/have you applied for disability through work? or if your disease is suspected to bypass a 12 month timeframe for recovery applied for Social Security Disability (www.ssa.gov)?

On a side note, if you are out of work now. Are you currently on medical leave? If your employer has over 50 employees and you have worked there for at least a year you may be eligible for Family Medical Leave Act, which protects your job up to 12 weeks. It’s important to discuss this with your employer to protect your job, and or apply for benefits that you may be entitled to. Some employers will also allow accommodations to work modified schedule or use their FMAA intermediately if working less hours is what you need as well.

I'd be happy to offer additional support if you are willing to share more information. Or you may contact us at 800-532-5274
Without specific information on your current health condition, treatment protocol and review of your disability plan, I am not able to tell you if you would qualify for benefits. Each disability plan have their own contract language that dictates benefits offered, when they start and how long and when they continue. Additionally, often the medical support of your treating physician(s) is necessary to support a disability claim. If your treatment and/or side effects are affecting your ability to work, review your plan and discuss going on disability with your provider. File a claim and await a decision. If you do find yourself denied, review the reason why and file an appeal. Patient Advocate Foundation wrote a publication called Your Guide to the Appeal Process available at http://www.patientadvocate.org/index.php?p=489.

Some areas I would request your review are:
1. Does the policy have a waiting period (period of time) before it will allow you to submit a claim?
2. Are there medical requirements you have to meet, i.e, cannot perform your job or ANY job; must be unable to work for at least 6,12 months etc.
3.Do you have/have you applied for disability through work? or if your disease is suspected to bypass a 12 month timeframe for recovery applied for Social Security Disability (www.ssa.gov)?

On a side note, if you are out of work now. Are you currently on medical leave? If your employer has over 50 employees and you have worked there for at least a year you may be eligible for Family Medical Leave Act, which protects your job up to 12 weeks. It’s important to discuss this with your employer to protect your job, and or apply for benefits that you may be entitled to. Some employers will also allow accommodations to work modified schedule or use their FMAA intermediately if working less hours is what you need as well.

I'd be happy to offer additional support if you are willing to share more information. Or you may contact us at 800-532-5274

A law was passed in 1996 to protect individuals who are seeking new employment opportunities or who simply would like to change group health insurance options. The Health Insurance Portability and Accountability Act also known as HIPAA (http://www.dol.gov/ebsa/newsroom/fshipaa.html) will provide anyone who has health insurance for at least 12 months and has had no break in coverage greater then 63 days an opportunity to pick up their new insurance without a pre-existing clause. Since some employers have a waiting period of 3 months before insurance will be in effect, but sure to elect COBRA benefits in the interim. Also under the Patient Protection and Affordabe Care Act, there are provisions in place to remove pre-existing health conditions starting in 2014 for adults and have already impacted those under age 18. (www.insureUStoday.org or www.healthcare.gov) Additionally, each state is mandated to offer a Pre-Existing Insurance Health Plan (www.pcip.gov) for when you are not eligible for other coverage and have had a lapse of 6 months or more.

Life insurance does not have any laws to offer the same protection. This is not an area of specialty for PAF, I recommend you speak to your employer human resource department about conversion opportunities or open enrollment options without medical disclosure requirement at the new employer or even a life insurance agent.
A law was passed in 1996 to protect individuals who are seeking new employment opportunities or who simply would like to change group health insurance options. The Health Insurance Portability and Accountability Act also known as HIPAA (http://www.dol.gov/ebsa/newsroom/fshipaa.html) will provide anyone who has health insurance for at least 12 months and has had no break in coverage greater then 63 days an opportunity to pick up their new insurance without a pre-existing clause. Since some employers have a waiting period of 3 months before insurance will be in effect, but sure to elect COBRA benefits in the interim. Also under the Patient Protection and Affordabe Care Act, there are provisions in place to remove pre-existing health conditions starting in 2014 for adults and have already impacted those under age 18. (www.insureUStoday.org or www.healthcare.gov) Additionally, each state is mandated to offer a Pre-Existing Insurance Health Plan (www.pcip.gov) for when you are not eligible for other coverage and have had a lapse of 6 months or more.

Life insurance does not have any laws to offer the same protection. This is not an area of specialty for PAF, I recommend you speak to your employer human resource department about conversion opportunities or open enrollment options without medical disclosure requirement at the new employer or even a life insurance agent.

Medicare offers a hospice benefit and many employer or private health insurance plans also include hospice benefits, although coverage for services varies.

For more about hospice, see our article: http://www.cfah.org/hbns/preparedpatient/Vol4/Prepared-Patient-Vol4-Issue3.cfm
Medicare offers a hospice benefit and many employer or private health insurance plans also include hospice benefits, although coverage for services varies.

For more about hospice, see our article: http://www.cfah.org/hbns/preparedpatient/Vol4/Prepared-Patient-Vol4-Issue3.cfm