Health Insurance: Detailed Information

Health insurance is insurance that provides coverage for health-related needs. It helps you pay for medical bills. The type of health care covered by your health insurance plan depends on the type of coverage and the amount you pay for the premium. A health insurance premium is the amount you and/or your employer pay for the benefits provided under your health insurance policy.

You can receive health insurance from:

• A group employer-sponsored plan
• An individual, private insurance plan
• A government program, such as Medicare or Medicaid

Because the medicines, visits with your health care team and tests used to screen for cancer can be very expensive, you may worry that without insurance you won't be able to afford the care you need during your survivorship. Trying to understand the differences between health insurance plans and how to make sure you get the best and most affordable coverage can be very overwhelming. There are organizations and resources that can explain the different insurance policies to you and work with you to get affordable health insurance that can help you pay for your health care needs.

What is an HMO? What is a PPO?

When learning about health insurance, you may often hear the terms HMO and PPO. These are two different types of health plans that are often offered by health insurance companies in the United States. It's important to understand the difference between an HMO and PPO when choosing health insurance.

• Health Maintenance Organization (HMO): An HMO is a type of health plan that provides a network of doctors, other health care professionals, hospitals, laboratories and other related services. You usually have to select from providers within your HMO's network or the care you receive won't be covered by your health insurance. The HMO may provide most of the care in stand-alone facilities or in community-based facilities.
• Preferred Provider Organization (PPO): A PPO is a type of health plan that also provides a network of doctors. However, the network is larger than an HMO, and you can go to any of the doctors, health care professionals and hospitals within that plan. You usually do not need a referral to go to a specialist. However, the costs can be more if a plan participant goes to a doctor or uses a service by a provider not within the plan. Usually, the premiums for a PPO are more expensive than the premiums for an HMO.

What are some of the reasons cancer survivors can have a hard time getting health insurance?

There are certain circumstances that may make getting health insurance difficult for survivors. It's understandable if you think these situations are unfair and they upset you. However, it's important to be aware of the circumstances because you may be able to avoid them. If you find yourself in these circumstances, you can often get help from an organization that specializes in assisting people who need health insurance.

A health insurance company asks you to go through medical underwriting: In most states, if you are applying for individual health insurance, not a plan from your employer, you may have to go through a process called medical underwriting. Medical underwriting means that an insurance company can look at your health history and medical records. The health insurance company can then decide if it will cover you at all. Sometimes they are willing to cover you but at a higher rate because you had cancer. Sometimes, the company will not agree to cover you if you have a pre-existing condition.

The health insurance company says you have a pre-existing condition exclusion: A pre-existing condition includes medical conditions that pre-date an application for a health insurance. An exclusion means coverage for that medical condition may not be covered for a specific time period. Your health insurance may cover other medical care, but you would have to pay for anything related to your cancer. The time period of the exclusion for group health insurance (usually through an employer) cannot be longer than twelve months. If you have had no actual treatment or recommended treatment for your cancer for the six months before you are trying to get health insurance, the company cannot claim that you have a pre-existing condition exclusion. If they offer you health insurance, they would have to cover any medical care related to your cancer. Also, if you have had health insurance for at least 18 months, the insurance company cannot use a pre-existing condition at all.

You haven't had any health insurance coverage for more than 63 days: It is extremely important to not go too long without health insurance. If you lose your health insurance for some reason, you should try to get health insurance within 63 days. This can help you avoid medical underwriting and pre-existing condition exclusions when you try to get health insurance again.

You are trying to get health insurance from your employer but have never had health insurance before: If your employer offers health insurance, they cannot exclude you because of your medical condition. However, if you have haven't had insurance for the amount of time required by the insurance company, you may be subject to a pre-existing condition exclusion for a certain period of time.

Fortunately, there are many resources available to educate you about your rights to insurance. Information is available through the Department of Insurance or similar agency in your state. There are also resources that specifically help educate cancer survivors about their rights to insurance. For more information on these resources, see Additional Resources.

Can health insurance companies cancel a survivor's plan because s/he had cancer?

Many cancer survivors worry that their health insurance company will cancel their policies because they had cancer. Generally, as long as you pay your premiums, the health insurance company cannot cancel you. If you have a private, individual policy and the health insurance company no longer provides that policy in your area, there is a chance you may be cancelled. This doesn't happen very often. When it does happen, the health insurance company will usually make another policy available to you.

When should a cancer survivor have health insurance?

Even if you have finished your treatment for cancer, it's important to keep your health insurance. Health insurance can help you pay for your follow-up appointments. Keeping health insurance is also important if you have a recurrence or a second cancer. Without health insurance, you would have to pay for any medications, visits with your health care team or medicines by yourself.

Are there laws to protect cancer survivors trying to get health insurance?

Changes in the laws in the last few years have provided more protection for cancer survivors. There may be more changes to the laws in the future that will provide even greater protections.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996, discussed in more detail below, is a federal law that provides certain protections that help cancer survivors get and keep their health insurance. It generally applies to people who have group health insurance, which is another reason why survivors with insurance from an individual, private health insurance plan may run into more difficulty when trying to get health insurance.

HIPAA does the following:

• Limits exclusions for pre-existing conditions
• Prohibits discrimination against employees and dependents based on their health status
• Guarantees health insurance will be available and renewable to certain employers and individuals
• Protects many workers who lose health coverage by providing better access to individual health insurance coverage

What are suggestions for survivors who are trying to pick the best health insurance for their needs?

Below is a brief list. For more information, see Suggestions.

• Find out what type of health care the health insurance plan covers and what things the plan doesn't cover
• Review the prescription coverage of the health insurance policy
• Find out if the members of your health care team are covered under the plan

This document was produced in collaboration with:
Barbara Ullman Schwerin, Esq.
Director, Cancer Legal Resource Center, a joint program of the Western Law Center for Disability Rights and Loyola Law School and Adjunct Professor of Law at Loyola Law School