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Patients Against Lymphoma

 

Support  > Insurance

Last update: 05/22/2015

TOPICS
Tips on Receiving Insurance Coverage | What if I have no insurance?  |  
Contact the Commissioner of Insurance for Your State | Lost Your Job?
Social Security Disability Insurance
 | Other types of financial help 

RESOURCES

 
Medicare Resources | Coverage | Articles | Insurance Info | Patient Advocate Organizations   |
Bone Marrow Transplant | Managed Care Terminology | Health Care Reform Updates

Key Resources:

Key Terms (below)

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Medicare Plan Finder for Health, Prescription Drug and Medigap plans http://1.usa.gov/1Eo9LbH
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Medicare & You  Medicare.gov http://1.usa.gov/1IPWPTV
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State-by-state health insurance options   Healthcare.gov
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Co-pay resources
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Exchange shopping for health insurance begins October 2013

This information is provided in the state of PA ... which should be about the same elsewhere.
The Marketplace
(overview of rules) http://bit.ly/15Pymtd  

The Federal Marketplace (shop Oct 2013- effective Jan 2014)  http://bit.ly/15PyGrK
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LOST YOUR JOB? AARP
Follow these steps to ensure you don't lose your health insurance and other important benefits, too.
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Financial Assistance and Other Resources for People With Cancer Cancer.gov
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Federal Social Security Disability Insurance: socialsecurity.gov 
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Map to your State Commissioner of Insurance: naic.org
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New: Choosing a Medigap Policy:
A Guide to Health Insurance for People with Medicare (PDF)
medicare.gov

Note:  Consider, of course, but double-check information on health insurance reform that comes from  groups that have political objectives.  Do this as you would when seeking medical advice: check for the source of the information - it should cite a section of the law or regulation.


Key Terms:

source: healthcare.gov/glossary/

Copayment (co-pay)

A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.

Deductible

The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan wonít pay anything until youíve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Out of Pocket Costs

Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

Out of Pocket Limits

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesnít cover. Some health insurance or plans donít count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

 

Tips from Patients:

Re: Denied SS Disability:

"It took two years, but only with the help of a disability lawyer did we get disability. Once we signed on with one, it did not take much time at all." - RL (cyberfamily)

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"You know the big "C word" keeps you out of many things. It's not suppose to but it does -- they call it discrimination. So if you have already been diagnosed, your in for a real fight to obtain any insurance other than Social Security, Medicare A, and B" - Keith

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Success Story: 

"I was told by the social worker at Stanford that small or mixed follicular NHL was a slam dunk for disability given I was undergoing a bone marrow transplant. I followed her advice and have been on Social Security benefits for over a year. However, my application was bounced back twice for more information. It includes a multitude of questions about previous employment and experience which looks like they're looking to see what else you could be doing if your disability precludes you from doing what you're currently doing. 

For instance, I'm a landscaper, but have been in sales. I stated emphatically that designing and building landscapes is what I do, and the fact that I'd done other things without passion and sometimes not very well, was irrelevant. Process took three months but benefits were retroactive. I believe you have to have not worked for 6 months before you're eligible, and that's the point the benefits begin accruing. 

Reading the accounts on the Lymphomation site made me think you might get discouraged and not try, so I wanted you to know it's possible. The money's not huge, $1,700/mo, but my two sons both get $400 each too, so it's covering the mortgage and their future college or whatever. Definitely worth the fight, in my mind."

- Mark (CA) NHL-follic

To treat cancer effectively you need an accurate diagnosis, access to experts, and state of the art medicines, which are costly and not always readily available to all who need them.

If your insurer denies payment for your treatment, don't give up. Most people do get payment eventually.

"If you have purchased your own insurance in the individual market, you are protected by state law. For example, many states have a patients' bill of rights. For details on your protections for obtaining and retaining health coverage, check out information for Your State.

In the News

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Health Care Reform Timeline: What's changing and when: http://www.healthcare.gov/law/timeline/index.html
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Social Security's Compassionate Allowances Program Means
So Much To People In Time Of Need  http://bit.ly/oW0YMo

Tips to receive insurance coverage for treatments

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Be well informed and familiar with your health insurance policy. 

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Prior to treatment, verify that your doctors, the healthcare facility , and the type of treatment you are receiving are all covered in your plan.

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Ask your medical team for a referral to a therapist or social worker who specializes in helping cancer patients with their finances. These specialists are a wonderful resource and will be able to help you cut through the red tape. 
 

What to Do If Your Claim Is Not Paid?  

Insurance companies may deny claims because they know there's a good chance the consumer won't appeal the decision.

FIRST, inform your health care team if you have been denied payment. 

ASK your doctors for Help and to tweak and resubmit the claim:  They can consult with your insurer and help answer questions about the treatment.

BE PERSISTENT:  Do not take a denial as final, many times they are not.

GET LEGAL HELP, if necessary ... initiating this action alone can change the decision.

OFF-LABEL USE?  Ask your health care team or hospital staff to provide insurance companies with studies showing that a particular drug is effective for your type of cancer. 

These actions are often sufficient.

What Else?

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Contact The Patient Advocate Foundation patientadvocate.org 

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Contact the pharmaceutical company for drug you received, and ask for information about reimbursement specialist hotlines . 

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As noted, if necessary, sue the insurance company to get payment 
for your treatment. Courts often side with patients and order insurance companies to pay for treatment.

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Contact the State Commissioner of Insurance for Your State.  See next item.

Contact the State Commissioner of Insurance for Your State

One of the roles of the State Commissioner is to "facilitate the fair and equitable treatment of insurance consumers"

 You can write or call the commissioner to report policies that you feel are unfair.

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Map to your State Commissioner of Insurance: http://www.naic.org/state_web_map.htm


What if you have insurance and lose your job?

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The Consolidated Omnibus Reconciliation Act (COBRA), was enacted to help.

"COBRA gives you the right to choose to temporarily keep the group health insurance benefits that you would otherwise lose after you reduce your working hours, quit your job, or lose your job. It also lets family members choose to keep health insurance after your job loss or other qualifying event that would normally cause them to lose the coverage they have through your employer."

See COBRA ACS

 

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AARP:  LOST YOUR JOB? aarphealthcare.com/
Follow these steps to ensure you don't lose your
health insurance and other important benefits, too.

What if you don't have insurance?

Healthcare.gov: State by state health insurance options for people with pre-existing conditions

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First, do not panic. Help is available from many sources:

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Contact your local health department
(in the government pages of the phone book or the Internet)

Ask what public health services are offered in your community. 

Ask for information about any "charity care" or "indigent care" programs.

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Contact your hospital's social service office,
which may be able to direct you to other sources of help.

Hospital social workers will be knowledgeable about sources of support in your community.

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Contact Medicaid:

877-267-2323 Web: cms.hhs.gov 
 
Medicaid makes health care services available for people with financial need. They may help pay for certain treatments. 

Contact the social service office  in your city or county to find out if you are eligible and if  your treatment expense is a covered. 

Begin early. The Medicaid approval process can take a long time.

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NEW Financial Assistance and Other Resources for People With Cancer cancer.gov

View more than 100 organizations nationwide that provide emotional, practical, and financial support services for people with cancer and their families.

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Review the free drug program

If the drug or company that makes the drug you need is on the lists that follow, you probably can get assistance to pay for it with the information provided here by NeedyMeds:  Drug Index | Drug Company Index

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Contact the National Cancer Institute
and inquire if you might be eligible for a clinical trials, preferably, perhaps, a study that is testing the standard of care against a  promising new protocol. 

NCI's hotline (1-800-4-CANCER).

* Contact the
an NIH Cancer Research Center

Also Contact the Patient Recruitment and Public Liaison Office at: 
1-800-411-1222, TTY 1-866-411-1010

Every patients is on a research protocol. 
Every citizen and permanent resident is eligible.
Patients from other countries are also welcome.

No one is ever denied.
Travel is paid when needed, as is lodging.
Includes a Children's Inn.

Specializing in rare diseases, and other serious conditions, 
such as cancers. 

Other types of financial help

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Free transportation or discounts for travel associated 
with cancer treatments  PAL

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Clinical Trials may provide treatment without cost, 
especially studies sponsored by the NIH  PAL

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Help with payment for drugs  PAL

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Financial Assistance and Other Resources for People With Cancer cancer.gov

View more than 100 organizations nationwide that provide emotional, practical, and financial support services for people with cancer and their families.

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See also Financial resources below.

Return to top

Tips about gaining social security disability insurance

SSA stands for Social Security Administration
Note: State laws may vary

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Disability claims require documentation based upon the medical records of the patient.

How We Decide If You Are Disabled? See socialsecurity.gov/  
 

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There are often two disability programs -- state and federal. 

To apply for Federal, see: socialsecurity.gov   
 

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In general, patients meet SSA standards for disability claims when it's determined that the malignancy is inoperable or beyond control of any other type of therapy.

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You can plan on at least three rejections, but you must go through the process for SS Disability. And plan on hiring an Attorney to represent you in front of the administrative law Judge which is the final process. The patient's doctor will be
instrumental in obtaining SSD. - Keith (patient)

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I have found that knowing how to reach the Commissioner of Insurance in my State to be an asset in my favor. - Keith (patient)

See for Map to your State Commissioner of Insurance: http://www.naic.org/state_web_map.htm

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Read the list of impairments for social security disability. List  every disability you have, and every  impairment, not just NHL.
See 2001bluebook.pdf   (PDF-Help) - Sue (Caregiver)

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A disability application is no place for personal pride.  State your disability strongly  It is no place to be "optimistic" as to your current or future abilities. - Sue (caregiver)

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The SSA will consider side effects from cancer therapy.

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If cases go to court, the judge is the arbiter of what is a reasonable fee, and usually cut the fee back.  Using an EXPERIENCED Social Security lawyer is a good idea.
 
For SS cases the fee is ordinarily limited to 25% of retroactive benefits.  One would have to wage a four year successful case to get that kind of a fee, though with our SS system, it's not unheard of.  - Toby 
 

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I can tell you long term disability insurance is a
paper work nightmare and full time job for the patient, or
family member to keep up to date. So too are the redundant
mailings to maintain your disability once you get through the first year and have received a favorable decision from the administrative law judge. - Keith (patient)

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Insurance Resources
Coverage
| Medicare Resources | Articles | Insurance Info
Patient Advocacy Organizations
| Bone Marrow Transplant

 
Coverage

INSURANCE COVERAGE

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Does Medicare cover  transplant for  lymphoma?  

This document might assist.  It looks like it is covered to us.

 
NC Division of Medical Assistance Medicaid and Health Choice
Hematopoietic Stem-Cell & Clinical Coverage Policy No: 11A-11
Bone Marrow Transplantation Revised Date: March 1, 2012 For Non-Hodgkin's Lymphoma

http://www.ncdhhs.gov/dma/mp/11A11.pdf 
 
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New: Choosing a Medigap Policy:
A Guide to Health Insurance for People with Medicare (PDF)
medicare.gov
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State by state health insurance options for people with pre-existing conditions http://1.usa.gov/fGvYoQ
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Map to your State Commissioner of Insurance: http://www.naic.org/state_web_map.htm
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Health Insurance Info.net
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About Denials and Appeals (insurance)  accc-cancer.org | aventisoncology.com  PDF 
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A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, 2003 Update  www.kff.org
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Insurance with Pre-Existing Condition ivillagehealth.com/experts
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Leukemia (CLL)  and Social Security Disability Claims  By: Pitt Dickey - Attorney  seniormag.com 
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Medicaid/Medicare Coverage Issues Manual  CMS
Use the Search button on the CMS site to locate specific topics.
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State Insurance Department Web Sites  naic.org 

Click the map or links below to go to that state insurance department's web site.
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The Health Insurance Portability and Accountability Act (HIPAA)
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High Risk Pools about.com
MEDICARE RESOURCES

(provided by the Leukemia and Lymphoma Society)

 

MEDICARE RESOURCES

Social Security Administration

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Application for help with Medicare prescription drug plan costs

Centers for Medicare and Medicaid Services (CMS)

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General information about the Medicare prescription drug plan:
http://www.cms.hhs.gov
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"Outreach Toolkit" for the Medicare prescription drug plan:
http://www.cms.hhs.gov
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Help and information for those with limited income and resources: http://www.cms.hhs.gov
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Health literacy 
- a guide to the best language to use when communicating with beneficiaries:
http://www.cms.hhs.gov
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CMS' extensive Q&A resource:
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Fact sheet link page for many of the subjects above:
http://www.cms.hhs.gov
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Vignettes to help explain how coverage works with/affects other types of health coverage
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Site for beneficiaries to find a doctor, learn more about the Medicare Modernization Act, deal with billing issues and learn about Medicare Advantage and Drug Benefit plan options:
http://www.medicare.gov
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To join CMS as an official partner to educate beneficiaries, caregivers and others, write to:
partnershipwebsite@cms.hhs.gov
Rating Insurance companies
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Look up your insurance company's financial rating 

Patient Advocacy Organizations

Patient Advocate Foundation
Headquarters
 
700 Thimble Shoal Blvd,
Suite 200
Newport News, VA 23606

Patient Advocate Foundation is a national non-profit organization that serves as an active liaison between the patient and their insurer, employer and/or creditors to resolve insurance, job retention and/or debt crisis matters relative to their diagnosis through case managers, doctors and attorneys. 

Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability.

800-532-5274
patientadvocate.org  | Email 
Cancer Care, Inc.
 
275 Seventh Avenue
New York, NY 10001
(800) 813-HOPE (4673)
www.cancercare.org
Financial Help Resource: cancercare.org/pdf/ financial pdf 

Entitlements Resource: cancercare.org entitlements.pdf 

Sources of financial assistance: cancercare.org Financial_Sources.pdf 
National Patient Advocate Foundation

National Patient Advocate Foundation seeks to create avenues of access to insurance funding for evolving therapies, therapeutic devices and agents through legislative and policy reform.

National Headquarters:
725 15th St. NW,  Suite 503
Washington, DC 20005
Phone: 202-347-8009
Fax: 202-347-5579
www.npaf.org | Email
District Office
700 Thimble Shoals Blvd.
Suite 201
Newport News, VA 23606
Phone: 757-873-0438
Fax: 757-873-1082
The Office of Patient 
Advocacy (OPA)
Staff provide advice, support and access to extensive resources and information. 
To speak directly with a patient advocate, call 888-999-6743. Their "resources page" is the same as the one on NMDP's site. 
Here's the OPA link: marrow.org

Financial Assistance

Contacts

Also see 
Drug Payment Support

Provides chemotherapy drugs to patients with financial need.
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American Cancer Society  800-ACS-2345 or local chapter

Provides free wigs, head coverings, financial referrals and resources to patients in need. 
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Financial Assistance and Other Resources for People With Cancer
 Cancer.gov
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Adria Patient Assistance Plan 
Adria Laboratories, 
P.O. Box 16529, Columbus, OH 43216-6529 
614-764-8100 
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Bristol-Myers Indigent Patient Assistance Program, 
Bristol-Myers Onocology Division, 
2404 West Pennsylvania Street, Evansville, IN47721 812-429-5000

Provides chemotherapy (Cytoxan) free of charge to patients with financial need. Request must be made by the patient's physician.
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American Association of Retired People (AARP)
Pharmacy Service. Catalog Dept., 
Box 19229, Alexandria, VA 22320. 

Members can use their nonprofit service to save on prescriptions delivered by mail. Good for tamoxifen (Novaldex). Write for free catalog.
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Help with payment for drugs PAL

Bone Marrow Transplants

National BMT-Link
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nbmtlink
National Foundation For Transplants
1102 Brookfield - Suite 202
Memphis, TN 38119
email: nftp@aol.com
www.transplants.org
800-489-3863
Assists those who need to raise funds for marrow transplants Maintains accounts to which tax-deductible contributions can be made.
National Transplant Assistance Fund (NTAF)
P.O. Box 258
Bryn Mawr, PA 19010
email: ntaf@transplantfund.org
800-642-8399
Assists with fundraising for all types of organ transplants.
The Bone Marrow Foundation
981 First Avenue, Suite 129
New York, New York 10022

212-838-3029 | www.bonemarrow.org
Nielson Organ Transplant Foundation
(Florida residents)
580 W. 8th St.
Jacksonville, FL 32209

904-798-8999
The Transplant Foundation
8002 Discovery Dr., Suite 310
Richmond, VA 23229
804-285-5115
Provides financial assistance for anti-rejection medication for transplant patients.
My Friends Care BMT Fund
(Michigan residents)
148 South Main Street, Suite 101
Mt. Clemens, MI 48043
810-783-7390

 

Disclaimer:  The information on Lymphomation.org is not intended to be a substitute for 
professional medical advice or to replace your relationship with a physician.
For all medical concerns,  you should always consult your doctor. 
Patients Against Lymphoma, Copyright © 2004,  All Rights Reserved.