How Do I Pay For My Medical Care?
If You Belong To a Health Plan
Each health plan has particular requirements for the payment of the medical services that are covered. These requirements, including the plan’s limitations and restrictions, are found in documents that are often referred to as a “Summary Plan Description” or “Evidence of Coverage.”
Medicaid and Medicare are public plans that have varying eligibility and coverage provisions. You are eligible for Medicare if you are 65 years of age or older, you have been on Social Security Disability benefits for 24 months, or you have end stage-renal disease. You are eligible for Medicaid if your income and assets fall within the income/resources criteria, if you receive Supplemental Security Income (SSI) benefits, or if you are determined to be “medically needy.” A separate section discusses these issues later in this handbook.
All plans provide coverage for certain routine visits, emergency services, and other medically necessary services. Excluded from coverage are pre-existing conditions and cosmetic and experimental treatments and other expressly excluded services or procedures. Each plan defines and interprets these terms differently and therefore a careful reading of the plan before agreeing to a service is advised. Unfortunately, the treatment or procedure that a doctor may recommend for your medical condition may not be a covered service under your plan. Check with your plan first and when coverage is not available, discuss options with your doctor.
The Bureau of Insurance at the State Corporation Commission publishes a very useful guide on health insurance in Virginia. For additional information, please visit the State Corporation Commission website.
If You Do Not Belong To a Health Plan
If you do not have health plan coverage at the time of your diagnosis or subsequently lose coverage, you should try to obtain coverage immediately. If there is a lapse in coverage, the pre-existing condition exclusion may prevent payment for medical conditions that existed at the time coverage was obtained.
Inform your health care providers of any financial limitations that you may have on paying for the necessary health care. Most hospitals and physicians’ practices will make payment arrangements with you and/or may provide services at reduced costs. The pharmaceutical companies have free or reduced cost arrangements for those who have limited means to pay for the drugs. The earlier this information is disclosed, the greater likelihood that satisfactory arrangements can be made. There are also foundations that will provide some financial support for out of pocket medical costs.
The following are suggestions may ensure that your cancer treatments are covered under a health plan should there be a gap in coverage:
► Find a job that provides group health care benefits that do not exclude pre-existing conditions; just because you have cancer does not mean that you can not work. Once you are in the plan (participation often begins on the first day of employment or the first day of the first complete month after the hire date; however, some plans impose a limitation period) your coverage will continue until your employment ends. The pre-existing condition exclusion may apply in your new plan.
► If you are employed and you lose coverage because of a qualifying event, you will be eligible for continuation coverage under COBRA. If you have been a member of the plan for at least 18 months you can convert to individual coverage if continuation coverage is not available.
► Find group health plan coverage through a religious, civic, fraternal, professional, or other membership organization such as AARP or the Virginia Farm Bureau. If you are a member take advantage of the group coverage offered, or become a member in order to participate in the group plan that they offer.
► Apply for Medicaid. Do not assume that you are not eligible. The eligibility rules are very complicated. Therefore, you should let the eligibility worker help you complete the application form. Because of your medical condition you may be determined to be medically needy and you may qualify. Call your local Department of Social Services or 1-800-552-3431.
► Apply for Medicare if you are 65 or older or if you have been eligible for Social Security disability benefits for a period of at least 24 months. Contact the Social Security Administration at 1-800-772-1213.
How Can I Be Sure That My Health Plan Will Pay For My Treatments?
First read and review your “Evidence of Coverage” or Summary Plan Description to determine what your plan excludes or limits. It also summarizes your rights of appeal.
Second, ask the medical staff. Generally they know what services are covered under the health plan. However, because each plan is different, before a costly treatment or diagnostic procedure is done, have your doctor call your health plan for official approval (some plans require pre-approval) or to confirm coverage. You should also make sure that you follow the restrictions in the plan such as calling within a certain time period after receipt of emergency treatment, pre-notification of hospitalization or out-patient surgery. In the case of HMO coverage, advance referrals for specialty care and certain services such as physical therapy and counseling are required. A costly mistake can be made by not checking with the health plan.