By Lisa Zamosky, Special to the Los Angeles Times
February 27, 2012
I need help finding affordable health insurance. I got insurance through California's Major Risk Medical Insurance Program in 1991 after having breast cancer. My premiums are now a whopping $1,209 each month! I have not had any cancer issues since the original bout, but I have been reluctant to change policies (assuming that I could find one). Can you help me find something more affordable?
It's smart to be cautious about changing plans, particularly given your medical history. But according to Michael Grodsky, an insurance expert for the nonprofit Cancer Support Community — Benjamin Center based in Los Angeles, there's no downside to applying for a new health plan to see what's available. Just don't cancel the coverage you have until you've secured a new plan.
The good news is that you're likely to find coverage at a price that's less than what you're currently paying, says Ankeny Minoux, president of the Foundation for Health Coverage Education, a San Jose-based organization that helps people find insurance.
According to Minoux, it's common practice for insurers to look back 10 years into your medical history to determine whether they're willing to extend coverage. Because you've been cancer-free for more than a decade, you're unlikely to be denied a plan on the basis of having a preexisting medical condition (assuming, of course, that you have no other health issues).
However, that doesn't mean your history with cancer is of no issue. Many insurers will ask if you've been treated for cancer at any point in your life, Grodsky says. When the answer is yes, it's a good bet the rates you're quoted will be higher than for someone who's never been diagnosed.
The best thing to do is work with a licensed insurance agent who is knowledgeable about the plans available where you live. To find an agent in California, log on to the California Assn. of Health Underwriters' website, http://www.cahu.org, click on the "Consumers" tab and then on "Find an Agent." You can find a licensed insurance agent in any state at the National Assn. of Health Underwriters website. Go to http://www.nahu.org, select "Consumer Information" and choose "Find an Agent."
If you run your own business, group coverage may be a good option. With just two employees (or, in a handful of states, only one), you can qualify for group plans, which are "guaranteed issue," meaning you will be offered a plan regardless of your employees' health conditions. The plan will cost more if employees have preexisting medical problems, but there are limits to the rate hike, which vary by state. In California, rates cannot be raised by more than 10% above the standard-risk rate, Grodsky says.
Although you're cancer free, it's worth mentioning that many states offer programs to help people with a particular type of cancer — most frequently breast, cervical or prostate — get coverage for screening and treatment. Eligibility depends not only on your illness but your income as well; typically you can't make more than 200% of the federal poverty level, which for a single person is $1,862 per month.
To learn about the public and private insurance offerings within your state, visit the Foundation for Health Coverage Education's website: http://www.coverageforall.org.
My wife was just diagnosed with stomach cancer. Her doctors recommended partial removal of her stomach. Our IPA (independent physician association) has been grossly inadequate in understanding the latest contemporary procedures, and my HMO has denied authorization for the surgery. What can be done?
It sounds as though there are two distinct issues here. The first is that you feel your doctor isn't up on the latest treatment for your wife's illness. The second issue is that you're being denied authorization by your health plan for a surgery that may be lifesaving.
When first diagnosed with an illness, it's a good idea to have another physician weigh in on your condition and the best course of treatment, regardless of how you feel about your doctor. "I absolutely think a second opinion is warranted," says Jennifer Jaff, executive director of Advocacy for Patients With Chronic Illness Inc. in Farmington, Conn.
In California, HMOs are required to pay for the second physician consultation. You'll need to request a referral from your doctor, and in urgent cases, state law requires your plan to respond within three days, according to the Department of Managed Health Care, the regulatory body that oversees HMOs in the state. But insurance plans throughout the country will generally cover the cost. "I've never seen an insurer deny a second opinion," Jaff says.
While your enrollment in an HMO requires you to see in-network physicians, you have the right to switch doctors and/or medical groups within the HMO if you're concerned that the care your wife is receiving is sub-par.
In addition, as a result of health reform, most consumers have the right to challenge their insurance company's decision to deny medical care through both an internal appeal (conducted by the insurer) and an external appeal (if your insurer rules against you). Your health plan must provide guidelines about how to go about the appeal process when it denies care.
In urgent situations, health plans must rule within 72 hours of receiving your appeal. Otherwise, they have 30 days for non-urgent cases and 60 days for cases in which payment was denied for medical services that have already been delivered.
These new rights don't apply to everyone, however. Health plans that were in place when the Affordable Care Act became law on March 23, 2010 — also called "grandfathered" plans — may be exempt from having to comply with the appeal regulations.
Your first step in initiating an appeal is to understand why the surgery was denied. A common cause of denials is a breakdown in the exchange of information between your doctor and your insurance company, says Candice Butcher, president and co-founder of Medical Billing Advocates of America in Roanoke, Va. For instance, your insurer could have requested additional documentation from your doctor, and the doctor has not yet complied. Follow up with both your health plan and your doctor to make sure paperwork justifying the need for surgery didn't get stuck on someone's desk, she says.
If that's not the issue, look to the medical reasons behind your insurer's denial. Then you and your doctor can refute those reasons or point out that the insurer's guidelines for care are out of date, says Cheryl Fish-Parcham, deputy director of health policy for Families USA, a healthcare advocacy organization inWashington, D.C.
If your health plan views the treatment as experimental, both Fish-Parcham and Jaff say you should collect medical journal articles that support the treatment's use. You can search for journal articles with PubMed, a service of the U.S. National Library of Medicine, at http://www.pubmed.gov.
Consumer assistance programs created by the Affordable Care Act are available to help consumers file appeals. To find one in your state, go to healthcare.gov, select "The Health Care Law and You," click on "Key Features of the Law," then "Rights and Protections" and finally "Consumer Assistance Program."
In California, consumers with HMO coverage can get help from the California Department of Managed Health Care at healthhelp.ca.gov or by calling (888) 466-2219. If you have a PPO, try the Department of Insurance (which regulates PPOs) at (800) 927-HELP (4357).
Is an appeal worth the effort? Yes, says Jamie Court, president of Consumer Watchdog in Santa Monica. "When patients go into independent review, especially expedited, the health plan usually backs down and gives them what they want," he says.
Zamosky has been writing about how to access and pay for healthcare for more than 10 years.
Got a healthcare dilemma? Email email@example.com or write to Health 411, Los Angeles Times Health, 202 W. 1st St., Los Angeles, CA 90012.
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