Tips for Getting and Using Health Insurance

Health insurance is available though employers, the government and private market. Learn how to shop for the best plan.

Presenter:  Jamie Ledezma Esq., Triage Cancer

This is a video of a workshop presented at the 2019 Celebrating a Second Chance at Life Survivorship Symposium

Presentation is 40:30 minutes, followed by 12:45 minutes Q & A


How you navigate the health insurance system depends on whether you have insurance through an employer, a government plan or through a private insurance policy. Understanding insurance terms will help you calculate the best plan for your needs.


  • The Affordable Care Act extended consumer protections for health insurance consumers
  • Pre-existing conditions and gender are no longer factors insurance companies can use to calculate insurance premiums
  • There are four different levels of health insurance available through the Affordable Care Act Insurance Exchanges that vary in price, coverage and deductibles

Key Points:

05:48 Understanding healthcare terminology

09:53  Differences between an HMO, EPO and PPO  

12:44  Beware of short-term insurance plans that lack federal protections

15:14  Protections available under the Affordable Care Act (ACA)

19:06  39-60% of patients successfully appeal a denial of coverage using an appeal process external to the insurance company

22:57  Attempts by some insurance companies to skirt the law

27:18  Medicare covers 58 million Americans and has four parts: A through D

28:48  Medicaid was expanded under the Affordable Care Act

31:58  Health exchanges created under the Affordable Care Act

37:05  Use to pick a healthcare plan that’s right for you

Transcription of Presentation

00:00  Great to meet all of you. I've met most of you when you walked in. Again, my name's Jamie Ledezma. I'm excited to be here with you. I applaud you for your brave courage to tackle legal issues with me at 8:30 on a Sunday morning.

00:14  I will try to make the law as fun as possible, but with that said, some of the information is really straight forward that we're going to go over today. The reason that I put that caveat is that the law is a very complex arena to navigate, and the beauty, why I fell in love with the law, is that it's always changing: the law is not set in stone.

00:42  So my caveat is we're going to go over this as clearly as possible in a way that you can get the information and be able to use it when you encounter legal issues next week or in two years in a way that you can refer back to the resources and the information that we give you in terms of how to spot a legal issue. Wait, are there some appeal rights? Are there some different mechanisms in place, either with my employer or with my health insurance policy, that I maybe can ask for additional coverage or get some greater protections? We're not going to necessarily have the answer to all of those issues today, but rather, hopefully direct you to the resources.

01:25 Introduction to organization Triage Cancer and its services:  I want to point out that Triage Cancer is an organization that covers a whole host of different legal issues for the cancer community at the national and state level. What we've passed out on each of your seats, as well as additional handouts before we leave, are examples, a sampling of those resources. We have all of our materials available in hard copy that we can provide to you. We also have materials available on our website, and we have, similar to this conference this weekend, we have our own conferences that are a full day of legal issues. We try to go to different regions every year. We'll be in Chicago next week, and in September, we'll be in North Carolina and Texas.

All of the services with Triage Cancer are free. Our target population are people who've been diagnosed with cancer at any stage, as well as their caregivers. We also work closely with healthcare professionals and employers. We're really targeting information in all different angles. We also provide many of our webinars that you can access for free. We record all of them, so you can go back and play them, but we provide our information in English and Spanish, and we also offer some continuing education credits for folks who are in the nursing profession.

02:48  Quick guides from Triage Cancer on Insurance Issues: One of the things that I've done myself, as a partner and attorney working with Triage Cancer, but then most importantly, as a survivor and a person whom my family and my friends use as the go-to person whenever there's a newly diagnosed member in our community, is I download these quick guides, and I have hard copies, onto my desktop. I just save them so when I have to go do a quick word search on FMLA, I can access that information quickly instead of jumping onto Google and getting lost again with all different resources. The quick guides are available for free and you can access specific issues.

03:26 State specific resources from Triage Cancer: We also have resources that are state-specific, as well as an overview of the national issues. State-specific, this gives you an idea, right? Every state is able to create their own system of protections for patients, as well as obligations of health insurance companies and employers. You can access that information by state.

03:49  Triage Cancer Conferences: Another great tool that we use in our conferences and our outreach events are some animated videos. This is an example of one of them. We just recently published a health insurance, how to shop for and select your health insurance policy. They're very short, two, three-minute YouTube clips.

04:07  One of our newest resources also is It's hosted on our website at There is a hard copy card available for you in your seat. This is a site that we host that really addresses financial toxicity associated with a cancer diagnosis. We know that having information on the front end, as you navigate your course of treatment including transplant, can possibly save you thousands or enable you to get access to important treatment. We are trying to provide a clear roadmap on how to access the most effective financial resources available for the cancer community.

That's our intro on Triage Cancer. Again, lots of resources on lots of different topics at the state level where you live, and it's all available for free. Please feel free to use our resources whenever you need it.

05:00 Where you get your insurance affects the road you have to navigate to get coverage of healthcare expenses:  Taking a look at health insurance, there are three main places where Americans get their health insurance coverage. The largest number of people get their health insurance through their employer, employer-based provided policies. The next group of insured individuals get their health insurance from the government, such as Medicare, or Medicaid, or even Tricare, military health insurance. And then we have the fewest number of people in America who access health insurance are buying it directly through the insurance company.

This is all important because it impacts what type of road you will have to navigate if you are trying to get something approved for coverage or appeal a denial. Let's take a look at what this means.

05:48 It’s important to understand healthcare terminology:  As we go into the next half-hour together, it's important that we have a clear understanding of the health insurance terminology. Something as basic as understanding the terms when used in your health insurance policy will, again, hopefully be able to allow you to maximize your coverage.

When we talk about a premium, we're talking about the amount you are going to pay monthly just to have that health insurance. You pay this whether or not you use your health insurance.

And then there are costs you are going to occur when you actually use your health insurance. Your first cost that we're going to highlight is your deductible. This is the amount that you're going to have to pay before your health insurance company will step in to cover any share of their cost for your medical care.

Their share of the cost is referred to as your co-insurance, otherwise known as your cost share. Your portion of cost share is the amount that you're responsible for paying after the insurance company pays their portion. If you have an 80/20 plan, that means you are responsible for covering 20% of the medical bill. You pay that until you have met your deductible.

A co-payment is the amount you are going to have to pay when you get care. For example, my policy has a $10 co-pay. Every time I go to the doctor, I pay that $10 co-pay. The caveat is your well visits under the ACA. We'll talk about that in a few minutes.

We talk about your out-of-pocket maximum. That's your deductible plus your co-payment plus your insurance. Your monthly premiums are not considered in your out-of-pocket maximum.

And then, as with everything in the law, the devil's in the details. Typically, your health insurance will only count payments made towards your in-network services, as to your out-of-pocket maximum. If you're accessing care out-of-network, that is not considered in your out-of-pocket category. We've also seen some insurance policies as of late, not all of them, but you want to double-check your policy, some insurance policies are starting to carve the deductible out of the out-of-pocket maximum.

07:58  I just want to go back and clear this up. Your co-insurance, if you have a plan that has a 20% co-insurance amount, that means your health insurance company will pay that 80% of your cost; you pay the 20% of those once you've met your deductible. But with a carve-out, your deductible is not considered in the out-of-pocket. You just want to double-check if that's you or not.

08:23 Example of how insurance cover works:  Let's look at David. It's a pretty simple example of how it could work.

For instance, David's plan has a deductible of $2,000. His co-insurance, he has a 80/20 plan. His out-of-pocket maximum is $4,000.

If David has $102,000 hospital bill, which we know that we can get those hospital bills in one hospital visit, what does he actually pay? His deductible is $2,000, that leaves $100,000 balance left. His co-insurance amount is 20%, so his cost-share is $20,000, but his out-of-pocket max is only $4,000. David pays the $2,000 deductible, plus $2,000 of the $20,000 co-insurance. David's total amount that he pays is $4,000.

09:22  Most insurance plans have a network of providers. These are doctors and hospitals that have contracted with the insurance company. If you go to a provider out-of-network, they may not be covered, but if you're in your company's network, the provider has already agreed to pay a certain payment for treating you. Regardless of whatever the provider bill is, they've negotiated this rate down, and that's what matters to your final cost, final cost that David is going to pay.

09:53  There are differences between HMO, EPO and PPO:  All three of these can be purchased, and they use a network of physicians, hospitals, and other healthcare professionals that work on your care team, your treatment team. Their goal is to give you the highest quality of care, but there are a few key differences. You have HMO, an EPO, and a PPO. The EPO is your Exclusive Provider Organization. The PPO's Preferred Provider.

10:25  With the HMO, the Health Maintenance Organization, you pick one primary care provider. All of your health insurance services go through that point person, your primary care doctor. It means you're going to need a referral before you see any specialist. Visits to your healthcare professionals outside of this network, outside of the HMO network, typically will not be covered by your insurance. I have a bill to show proof for that, that I have to call and try to appeal when I get home on Monday.

For example, if you have a rash, we don't get to go directly to the dermatologist. We have to go to our primary care provider first for that referral.

If your primary care physician cannot help treat that condition, they're usually more than happy to get you to a referral for an in-network specialist. This helps lower cost of care for everyone involved, including the patient and the treatment providers.

11:22  Your EPO, it's a larger network than your HMO, but they typically don't pay for any services obtained outside the network. Typically, there's going to be no out-of-network benefits with your EPO. And a PPO is going to be a different version than the HMO. HMO and EPO are similarly situated.

11:41  A PPO, rather, gives you the most amount of flexibility. You don't have to have a primary care physician. You do not need a system of referrals before seeing a specialist. You can see anyone you want. What you're agreeing to, what your health insurance company's agreeing to, is to provide coverage if you stay in-network. If you go out-of-network, you may have to pay a higher cost in terms of the services. The benefit with a PPO is it will mean fewer appointments on your end: one less step of getting to your specialist.

12:15  The best plan depends on your needs:  The question that comes before us often is which is the best plan? It really depends on your needs, particularly your location, and what your service network looks like. Meaning, what's your home hospital? Where do you want to be treated? As well as your physicians, what do they carry? And then the big million-dollar question is the cost, right? Affordability is the biggest issue for most of our families.

12:44  Warnings about short-term plans offered by some insurance companies: Some health insurance companies also share short-term plans, and this is really a plan that is aiming to lower your monthly premium, but we want to give a word of caution with these plans and be very weary of them. For those of us in the cancer community, we know these concerns all too well, but our family and friends, who haven't had to deal with a diagnosis, may be tempted to jump onboard with a short-term plan.

The short-term plan, the reasons that we have concern is that they don't provide the same patient protections as the comprehensive plans that have been expanded under the Affordable Care Act. They're able to deny selling to individuals health insurance, and they're able to exclude particular treatments for those who have pre-existing conditions, and that would be anything that falls within the cancer diagnosis. Additionally, many of them have very high out-of-pocket costs for minimal coverage. This ends up costing more to individuals in the long-run. They were able to bring down their monthly premium, but they're having to fork out a lot of money just to address a flu diagnosis or pneumonia.

These plans are also not considered credible coverage since they are not required to renew coverage year after year. That means if these plans end mid-year, it does not trigger a special enrollment period, which is referred to as the SEP, which allows you to jump into the marketplace to buy an ACA plan. This typically leaves people uninsured during a significant life event, which is a diagnosis or a period necessitating treatment for those of us in the cancer community.

The plans were supposed to be eliminated from the marketplace with the passage of the ACA, but what we've seen, because the law is not set in stone, what we've seen is that the plans have actually grown. Currently, we're waiting for a final rule from the Health and Human Services Agency to consider whether or not to allow people to buy short-term insurance plans for up to 364 days. They were previously limited to three months, so a gap, but now they're going to be expanded to even a longer period. We just want to make sure, again, that consumers understand what they're buying and the potential pitfalls, especially for those of us, again, in the cancer community.

15:14  Protections in Affordable Care Act (ACA) Plans: When talking about an ACA plan or a plan that meets the ACA requirements, we saw some pretty significant consumer patient protections and benefits that address the cancer community. The first being no lifetime or annual limits.

When I was diagnosed in 2007, I had a great double-coverage policy from my employer and my husband's employer. We had PPO, the gold star health insurance plan in our community. Both of our plans had a $1 million lifetime limit. I was 27-years-old. I had one surgery where I got a bill from Stanford Hospital in excess of $300,000. I was confident that if I made it to my 30th birthday, I was going to bankrupt my family.

Fortunately, between 2007 to my 30th birthday was the period the ACA was passed. Because of that, annual and lifetime limits were eliminated. As long as I maintained coverage, I didn't have this $1 million limit hanging over my head. It really changed the landscape for whether or not you look forward to your 30th birthday or not in terms of financial toxicity of cancer.

16:31  We also saw, particularly for the cancer community, but for all people insured, no rescissions or cancellations. You may remember also during this time period, there were quite a few coverages of high-profile cases, and all too often where individuals post a cancer diagnosis were having their insurance companies look back at what their health insurance application included, and perhaps they forgot to include that they had their tonsils removed when they were 14. Because of that, a cancer diagnosis 25, 30 years later, they were all the sudden having their policies rescinded post-diagnosis. That is no longer permitted under the ACA.

17:16  Young adults can stay on their parents plan until their 26. Free preventative care, except for grandfathered plans, which are far and few between. In fact, I have not seen a grandfathered plan, meaning it was in effect at the time the ACA passed and has not substantially changed since. The free preventative care, which most of us are entitled now, means no co-payments, no co-insurance, and no-deductibles will be applied to wellness or prevention visits. Examples would be immunizations, physicals, blood pressure, diabetes checks, a lot of your baseline checks. It also included mammography coverage for women over the age of 40.

17:55  Clinical trial coverage was a big win for the cancer community to be included as a patient protection, which meant that if you were participating in a clinical trial, that your basic, essential benefits must be applied to that clinical trial process and procedure: blood draws, checks by your physician.

18:17  Another significant component of the ACA was that we expanded the requirements of having an external appeals process. Most insurance companies do have an internal appeals process. Appeals in the insurance arena, and really, in dealing with a cancer diagnosis, whether it's your employer or insurance or SSDI, is something that we should become pretty comfortable with is appealing, and really trying to assert your right to gain coverage, which will hopefully improve outcomes in the end. The details vary on what your appeal process will look like based on your plan. Individuals need to check their specific policy and look at what that first step is, which is the internal appeals process.

19:06  All states are now required to have an external appeals process after you exhaust your internal appeals. This is often referred to as an IMR, your Independent Medical Review. The details vary as to what the external process will look like, and it's usually governed and operated through your state insurance agency. Our website at has compiled a list of all the contact information for your state insurance agencies, and what the appeal contact is on our website under State Resources.

19:39  Appeals of denial of coverage are often decided in favor of the patient:  The reason that you want to get very comfortable with this idea of going through the appeals process is because a 2011 study showed that between 39 to 60% of the appeals were decided in favor of the patient. It really is in your best interest to consider appealing. In fact, we've started seeing some areas of coverage where insurance companies are making future coverage decisions based on the frequency of appeals that they've seen in the past. For example, in the case of coverage for fertility preservation prior to cancer treatment. Because of the appeal history that we've seen, insurance companies are starting to build that into their approval or denial process.

20:34  The ACA also made significant changes to how insurance companies decide who to sell insurance to and for how much money. The ACA said that health insurance companies can now only consider four factors when deciding what they're going to charge individuals. This is otherwise known as the Premium Rating.

Today, under the Affordable Care Act, insurance companies can determine the amount that they will charge you based on whether or not you're an individual or a family plan; your geographic location, and for example, in California, there are 19 different regions. It's not just by state. It can be multiple regions within your state; your age, and it's usually once you hit the age of 64, then there can be an additional charge; and then your tobacco use, whether or not you use tobacco. Those are the four factors insurance companies can consider in setting your premium rate.

21:38  This is important. Pre-existing conditions and gender are no longer a factor in setting how much insurance companies can charge you every month. The ACA said that insurance companies can no longer deny selling a policy or providing coverage for care to a person because of their pre-existing condition. This is a game changer.

It's important because one, you have a right to buy a policy with a pre-existing condition, but the other component is that you can't set my price higher because of a pre-existing condition, and that's the big piece, the Premium Rating. It's great if you will sell me a policy regardless of my history of cancer, but if you're going to sell me a policy at $5,000 a month, I'm never going to be able to attain that. It's all relative. It's important that these two components work together: the pre-existing condition protection with the Premium Rating, that you're not looking at my pre-existing condition as a factor to set what my premium is. To be truly meaningful in the cancer community, these two conditions have to work together.

22:57  Attempts by insurance companies to skirt the law:  In the last few months, we've seen some unprecedented approaches to trying to skirt around the law. For example, in January in Idaho, there was an announcement to allow insurers to sell health insurance that doesn't necessarily comply with the ACA. Health insurance plans would be able to deny coverage to people with pre-existing conditions or be able to work around the Premium Rating and set higher Premium Rates for these individuals. Ultimately, CMS set out a response to Idaho's proposal, and it did not go into effect, but the approach, the attempt in doing this was quite concerning in terms of the direction that we're going for the cancer community.

Other states, like Iowa and Tennessee, took another very novel and creative attempt at trying to avoid ACA requirements. The Iowa Farm Bureau, for example, partnered with an insurance company to sell a new product, not health insurance, but health benefit plans, which don't have to comply with ACA requirements because it's not a health insurance policy; it's a health benefit plan. It avoided barring medical underwriting and avoided annual and lifetime limits. The tactic of getting around ACA requirements by defining a new plan avoids this policy, this benefit package, from scrutinizing or oversight by the insurance agency of your state. Again, it will come into play when you're trying to appeal for coverage.

All of the decisions at the really grassroots level will have a larger impact on what the overall health insurance arena and marketplace looks like. We, at Triage Cancer, are continuing to watch some of these changes at the local level. And again, the beauty with the law is that it's always changing, but the challenge is as we take two steps forward for patient protections, every now and then, we see a step back. We are continuing to monitor this situation.

25:14  There is no penalty today for not having health insurance:  In terms of the requirement to have health insurance, which was adopted under the Affordable Care Act, we do see in 2019, the takeaway is that there is 0 penalty. Where we are today is if you are in a situation where you do not have health insurance, or more importantly, your family or friends are telling you that the IRS, there is no penalty imposed today.

25:40  Challenges to Affordable Care Act:  Where are we? I keep referring to the Affordable Care Act because that really is where we are today. It still is in effect, but we've seen a very tumultuous effort at trying to poke holes in it. Some of those holes have been successful, which makes the foundation which the ACA was built on, a bit more weak. We're continuing, again, to monitor it. Some of the challenges started before 2018, but the slide is only so big.

What can you see is that originally, we see some approaches by various states, including 18 states in February of 2018 that tried to challenge the constitutionality of the ACA, where today, we are now waiting for an appeal decision by the Fifth Circuit Court of Appeal on whether or not the case will be going to the Supreme Court, which it will likely go to the Supreme Court in terms of its in effect. Today, certain provisions have been ruled unconstitutional, but as a whole, it is still in place to protect patients.

The pre-existing condition is something that you hear in the media a lot. Last year, there was a particular push to amend and eliminate the ACA, and really, the piece of pre-existing conditions, I think, is what kept it hanging on. We'll see where we go going forward. Again, Triage Cancer will monitor that. We have blog updates on each of the case rulings as they come out by the court.

27:18  Medicare covers 58 million Americans and is a program funded by the federal government. To be eligible for Medicare, one must be a US Citizen or a legal resident, and is also over the age of 65, and has been receiving SSDI for two years, or end stage renal disease or ALS.

The main resource for Medicare is You have to be careful in terms of the information, the mailers, that are sent to you. Your mailbox is probably full every single day if you're even within arm's reach of Medicare coverage. Some of those attempts are really profit attempts at your expense. Some of them are scams. Be very careful, make sure you're accessing to double-check or using a reputable resource.

28:11  There are four parts to Medicare, A through D. This is not a Medicare session. I do have a quick guide on that. We're not going to go into all the details on Medicare. There is a webinar on our website that we did recently. You can download that and listen to that. We also have this quick guide, I have the hard copy, and we can share that before the end of the day. Also, depending on the state that you live in, there may be a resource available to you called a SHIP program, which helps. Essentially, it's a patient navigator or an insurance Medicare navigator to make sure that you are choosing the right plan with the necessary coverage.

28:48  Looking at Medicaid, Medicaid was expanded under the Affordable Care Act. Before the Affordable Care Act, there were four ways to get into Medicaid coverage. You had to meet either one of these doors, you had to go through one of these doors to get Medicaid coverage, but all of these doors required low-income and low-asset threshold. It was not only opening the door, but it was a limbo test; you had to go under and through the door.

For people coping with cancer, before the ACA, most of them entered into the system through the age, blind, and disabled category. The challenge was that if we saw individuals who had any significant retirement accounts, savings accounts, even cars, assets that precluded them from coverage, they were having to spend down to make sure that they met the threshold. The spending down effort in order to access life-saving treatment and care really put our families and patients into some dire financial situations.

29:58  Expansion of Medicaid:  We know that bankruptcy in the United States, the number one cause of it is significant medical diagnosis. Thanks to the Affordable Care Act, we had Medicaid expansion, which does not require an income or asset threshold under the new category, which is your attempt at trying to expand was the ACA was that individuals with incomes at or below 138% of the federal poverty level, in dollar terms, it means people who are roughly making about $16,000 a year as an individual, they did not have to do an asset test.

When the law was written, the idea was that all states would expand Medicaid into this new door, this new option. The Supreme Court, in one of its decisions addressing the Affordable Care Act, did make a ruling, a decision, that this needs to be voluntary on states. It cannot be mandatory. Because of that, the Medicaid expansion went slower than originally planned, but it has taken quite a few steps, which is a good sign, in terms of expansion.

We still have our original four doors. We do have this fifth door, which is voluntary for states, and fortunately, based on 2019 numbers where we are, 37 states have voluntarily expanded into the fifth door. 14 states have not expanded at this point. That does not mean that they do not have plans to expand.

The beauty, why the law, I think, is so exciting even on a Sunday morning, is that these footnotes, you don't need to know the footnotes, but it gives you a good idea of how quickly things change all the time. That shows you the sequence of expansion at the different states. They've all taken steps based on their own local needs. It's happening slowly, but surely.

31:58  The ACA created health insurance marketplaces, which is what you hear as the Exchange. We think of the Exchange as traditionally, a brick-and-mortar shopping mall, or based on the millennial generation, we now all have the benefit of the Amazon shopping cart. That's what your Health Insurance Exchange is. It's your Amazon website. It's this idea that you can go and compare products all at one spot, and put them in your cart, and know what you're going to pay before you check out and click and buy.

The quality control is in place that allows anyone to sell in this Amazon of health insurance called the Health Insurance Exchange. Anyone who wants to sell their product has to meet quality control mechanisms.

When I gave this word of caution on the front end about the short-term plans that did not provide comprehensive coverage, they're not on our Health Insurance Exchanges. You have to be able to make sure that you meet certain requirements and you have an out-of-pocket max that is at or lower than $7,900 for an individual. In addition, if you buy a plan through the marketplace, there are financial assistance programs, either a tax credit or a subsidy, available for purchasers.

33:17: There are four different categories of healthcare on the Exchanges: One thing the marketplace tried to do, when you go to Amazon or our Health Insurance Exchange, is to simplify the process. We have four different categories of plans that you can buy. You have a bronze plan, silver, gold, and platinum. A bronze plan has a 60/40 cost share. A silver plan is 70/30, but now some of them may be 66; a gold plan is 80/20; and a platinum plan is your 90/10 in terms of cost share.

Typically, your bronze plan will have the lowest monthly premium, but it has the highest out-of-pocket cost. Your platinum plan has the highest monthly premium, but the lowest out-of-pocket cost typically. Consumers can now shop for health insurance just like you shop for the last product that you did on Amazon.

34:14  Subsidies for healthcare on the Exchange:  People below 138% of the federal poverty level or eligible for Medicaid. People between 138% and 250% of the federal poverty level, so are $30,000 a year, will be eligible for cost sharing subsidies if you buy a silver plan. People between 138% and 400% of the federal poverty level will be eligible for a tax credit. And some people are eligible for both the subsidy and the tax credit, depending on where you fall on the chart. These are only available on silver plans.

34:53  You can enroll a number of different ways. The easiest way would be going to the website, but you can also call, or you use a paper application. In some jurisdictions, there is an assister, again, a navigator, but an assister available to help you in-person go through the steps in terms of enrolling in an exchange plan.

35:15  When to enroll? It changes depending on what your source of insurance is going to be. Enrollment for Medicaid, at any point during the year if somebody becomes eligible, you can submit that application. Open enrollment for 2019 is closed for marketplace, but for 2020, we expect it. It's based on the same dates to be around November 1st to December 15th, but those specific dates have not been announced yet. Medicare every year is October 15th to December 7th, and employers typically are in the fall.

35:52  Special Enrollment Period. Under the ACA, it codified, it acknowledged that life doesn't just happen during open enrollment period, right? We have what is called SEP, Special Enrollment Period. When you have a life-changing event that results in a loss of coverage, you have 60 days to shop for an insurance plan in the marketplace, but it's really important that you figure out what plan you want, what approach you want, and you have to stay in that lane.

36:20  You can have COBRA or State COBRA. We have a quick guide available on that if you want to pick that up. You can buy an entirely new plan on the Amazon of health insurance, on the Health Insurance Exchange, during your 60-day period; you may be eligible to jump onto your partner, your spouse's plan, or domestic partner; if you're under 26, you can jump onto your parent's plan; or you may be eligible for Medicare or Medicaid. But it's important that once you pick that plan, you can't change a few months into it. You can't pick COBRA and then try to go into marketplace at month three deciding that COBRA's too expensive. Once you pick COBRA, you have to stay at COBRA until the open enrollment period.

37:05  How to pick a plan?

Picking a plan? You have to do the numbers. Comparing apples to apples, it can work in any equation. This is an overwhelming chart. The idea is just pick two plans and compare them together. Let's look at what this plays out to be. You have to do the math. Let's take the marketplace.

37:30  Example of how to compare programs:  We're going to assume the bronze is the cheapest monthly premium, right? The middle category is your silver plan, and then your most expensive plan based on premium is platinum. Assuming someone is in the cancer community, let's say we're going to reach our out-of-pocket maximum. Which plan actually costs you the least? Can you tell by looking at this?

I like the way your brains work. You're going to take the monthly premium, you're going to multiple that by 12, and then you're going to add the out-of-pocket maximum. Here you see that with option one, your total is going to be $8,000 a year. With option two, the silver, it's $8,400 a year. Option three, the platinum, it's right under $6,000 a year. So yes, the platinum's going to be your best bet, assuming you hit your out-of-pocket maximum.

38:29  Don’t compare only premiums – compare overall year-end costs:  Some things to keep in mind is it's not just the monthly premium; we have to look at the cost of the overall year-end cost.

Also, while cost is a huge driver for most of us, it's not the only thing. You develop a trusted relationship with your treatment team and your provider, so it's important sometimes to us, we will move mountains to the end of the earth to make sure that we have an insurance plan where we know our provider's going to accept it.

Depending on your situation, cost, you have to do the math. It's not always what's the lowest monthly premium, and then the other component is the practical and logistical impact of if you're picking a plan that has a treatment center, but that treatment center is three hours away, can you do that? We understand the practical realities of it. There are other factors, including prescription coverage, to look at.

We also, again, have an animated video available on some of these resources with health insurance: prescription drugs, checking facilities.

39:36  Another example comparing HMO and PPO:  Last case is of Madeline. Three different plans. She has an HMO, a PPO, and another PPO. What other things should Madeline be looking at?

In this example, the PPO with the highest monthly premium of $200 ends up costing her the least at the year-end, but she has all of those other factors to consider. What about her drug coverage? What about location? What about providers?

That wraps it up for health insurance basics. I'm happy to answer questions. With that, I will be available afterwards if you have one-on-one questions about your specific issue. My disclaimer is the law always changes, and the other disclaimer is it's not legal advice; we are empowering patients and the cancer community to access resources, so you can advocate for yourself, but I would love to answer questions. Thank you.

Question and Answer Session

40:31  Everybody could use the microphone. We're recording this session.

40:34  [audience question]  When to take Medicare:  Yes, I have an individual policy. Well, and my wife. My wife recently got the SSI for two years. She can get Medicare as of August of this year. This caught me by surprise. I'm not sure which would be best, which I got, and how long will this Medicare last for? I mean, I have idea how long the Medicare would last which they said she gets in August.

[Ledezma]  We're going to have a workshop later this morning where we're going over a bit of SSDI and SSI. Your Medicare coverage is going to be a personal decision, but typically, it's going to be a good move. You'll just want to make sure that you understand Medicare Parts A through D, and that you understand the holes that exist, the gaps in coverage, and I have this. Did you find it already?

 I have a chart on Medicare and that I'll get you. But you'll want to get comfortable with Medicare. That should provide great coverage for your wife

41:36  [ audience] How long will it last for? It's her life or we go back-

41:41  [Ledezma] As long as she's in treatment, as long as she needs it. Yeah.41:57 [audience question] When you have two policies, which becomes the primary?  I have, right now, a coverage with my husband, but I'll be approaching two years of my SSDI in August, actually. Which becomes the primary and the secondary? Can I have both? Because right now, I have a $15,000 out-of-pocket max and a 20% co-insurance, so that's like, I'll be meeting that in three months. Probably in a month's time, I'll be getting all the bills.

42:29  [audience] I want to have as much, of course, savings as much as possible. Will my husband's plan become my primary and the Medicare be secondary? How does that work if I keep both?42:43  Medicare will be your primary.

42:53  [audience comment about Medicare] Just for transparency's sake, I work with folks in Medicare here in the state of Florida, and I think one of the things that's really important to understand is that when you are turning 65, you know health questions are asked. It's a perfect opportunity for you to be able to move a plan that is perhaps better than what you had when you were pre-65 because very often, there are limits on that. And if you ever want to move between plans, you have to medically qualify, so making sure that you understand, as you said, all of the components of it, and that the Advantage plans have out-of-pocket costs. Exactly what you presented up there. It's just really important.

43:37  [Ledezma] And I think that because of the unknown, a lot of us have concerns in terms of what does that coverage actually look like when we have to go access the care that we want, which is the best care available? And Medicare meets that threshold. Medicare is a great alternative. You should feel comfortable and confident in your healthcare, and if not, there are, through CMS, ways to challenge the coverage if you're not getting it because it does provide the most comprehensive, robust coverage we have available.

Did that answer your question?

44:15  [audience] Just for a follow up, because I'm on SSDI, how long ... Well, I don't know how long I'm going to have it because I'm sure I'm going to have reviews every now and then. Medicare ends too if my SSDI ends?

44:32  [Ledezma] You would work, and I would love for you to jump in on this, but I would say we all want a plan, right? That's the nature of providing security for our family. It would be best to talk with your doctor, but I think once you get on it, you should be fine riding this one out on Medicare. Your biggest advocate for all of you, regardless of what type of coverage you have, your biggest advocate will be your doctor. When you go through that appeals process, you need to use your doctor because at the end of the day, the threshold is, is it medically necessary? Then you get to keep your coverage. If it's medically necessary, then it should be covered, and you keep your coverage.

45:22  [audience] Concern about losing ACA coverage: My question is, at this point, my husband is already $2 million plus in his, you know. If the ACA, if they get their way and they take it away, we're freaking out because we're going to be bankrupt. I know you don't know what's going to happen, we don't know what's going to happen.

45:46  [Ledezma] Yeah. I actually had the wonderful honor of speaking on the Hill. I gave a presentation. I was able to address Congress last summer in June, and it was on the issue of pre-existing conditions, and what my future and loss of hope looked like with the annual limit and lifetime limit imposed.

The law, it's scary, right? It's exciting. I love my job. The law always changes and, it can just be pulled out from right underneath our feet. That is horrifying, but the good news is we can do something about it, right?

 In the meantime, we hope that, especially the cancer community who I believe, I firmly believe from personal and professional experience, has the most to lose out of this, so there is an opportunity. No one knows, but there's an opportunity for your voice, and please, continue to engage with BMT Infonet. Continue to engage with the rest of the cancer community, the larger national cancer community, because it really does matter.

The ACA is called the Affordable Care Act, which I know there is a lot of dispute on the affordability component, but the other part of the long legislative title is And Patient Protection Act. It truly does provide patient protections for the cancer community. Affordability? We need to work on.

I don't know what the future holds but, engage.

47:21  [audience] Question about what to do when a person turns 26 and loses coverage under parent’s plan:  Okay. My question is I'm on my dad's insurance still and I'll be 26 next year. The insurance that did the most help with me was Blue Cross Blue Shield. How would I go about trying to cope with that and still do what I have to do for myself as a cancer patient?

47:46  [Ledezma] I would love to jump online right now. Have you done it yet? Have you punched in exchange? You can go into the, I think, and start punching in where you live, Georgia, they're from Georgia, and your age. Let's put in your age as 26, 27, and start seeing what your plan options are and your rates.

Then you can at least, for planning purposes, look at what that forecast looks like. You don't have to buy insurance through the marketplace. You can buy it directly through the insurance companies, but the best place to start is the marketplace and see what your coverage is, what your options are, and do the math, remember?

You don't just want the lowest monthly premium. Maybe, but do the math. Play it out. We'll come back here.

48:36  [audience] This is kind of a follow-up question. My daughter will go off my plan in the period of time. Typically, when you're looking at that, are the company-provided plans generally more beneficial? I know going to the website, like you just said, but from what you're seeing in statistics, are the private company plans providing broader coverage than going through the state or national websites to buy insurance?

49:03  [Ledezma] Where do you live?

49:04  [audience] Massachusetts.

49:08 [Ledezma]  I don't have statistics as to whether marketplace plans provide better coverage than plans directly, but I do know that the marketplace, the Health Insurance Exchange, what I now call Amazon of health insurance, was built based off of Massachusetts. I would start looking at forecasting as to what your exchange looks like.

 Where do you live?

49:32  [audience] Florida.

49:33  [Ledezma] Florida? Sorry. To go back to your question, regardless of what happens at the federal level with the ACA, a bit of saving grace is at the state level, and many states, and we'll talk about this in my next session, many states go above and beyond what the federal level requirements are. Not all states, sorry, but Massachusetts would be an example.

In terms of what your comprehensive coverage provides, I think you are going to have a number of different options. I would just have to start doing independent research on what a private plan looks like versus an exchange plan.

50:26  [audience] Question about what happens to younger wife when spouse goes onto Medicare: I got cancer when I was 58 and I'd worked at my job for 38 years. Luckily, the only employer we've ever had, he continued to pay me for a year and a half, so I'm back to work some, and I'm working, and I still have my same healthcare plan. Of course, that's very scary if the business was bought out or whatever. I would be the first one gone.

 But my main question is for myself, I'm going to try to work until 65 so I can still have my healthcare, but my wife is younger than I am. How does that work when I hit 65 and I want to get on Medicare right then because that's the best insurance I can get to help me with cancer at the age? What does my wife have to do for insurance?

51:23  [Ledezma] Most often you can find, just with what's in the marketplace, depending on the size of the employer, sometimes if you're close in age, some employers will allow someone who is six months in turning-

51:39  [audience] Multiple years.

51:40  [Ledezma] Multiple years? I would say look in the marketplace. Most times, you can find that, whether it's that or through private insurance.

So you're going to have two different policies, two different terms of coverage. Which is not a bad thing.

51:56  [audience] Which is at 65, that's what I want to do [inaudible 00:51:59], right?

51:59  [Ledezma] Yes. And again, it's not a Medicare presentation, but make sure anyone who's in the Medicare marketplace, you look at what your gaps are going to be, and because we're in the cancer community, you want to make sure you have robust, you fill all those holes. It's great coverage but, look at gaps.

52:16  [audience] Question about out-of-pocket costs are based on the full hospital bill or negotiated rate:  This will be a quick question. I know it's not right now, but let's say what's interesting is my wife's medical bills are like $960,000. However, since we had insurance, really between insurance and my deductible, paid $16,000, which is totally ridiculous, the difference between the two. Now, if they had the thing where they say the limit is a million dollars, which would they have gone by, the $16,000 or would they have gone by the $962,000?

52:42  [Ledezma] It would be based on the negotiated rate.

52:45  [Ledezma] Mm-hmm (affirmative). Yes. If everybody heard that question, do we look at what the hospital bill says or the negotiated rate between the insurance company? And it's the negotiated insurance company rate.



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