Tips on How to Get and Use Your Health Insurance

Options for obtaining health insurance, current laws, how to compare plans, and appealing a denial of an insurance claim. 

Presenter: Joanna Fawzy Morales Esq., Triage Cancer

Time:  55 minutes


Health insurance is a necessity for patients undergoing a transplant. Learn what types of plans are available and how to choose the plan that’s best for you.


  • Protections for consumers vary depending on whether they get their insurance through an employer, the government or directly from an insurance company
  • To analyze which healthcare plan is right for you, consider all the costs, not just premium, as well as whether it covers your preferred doctors and the prescriptions you need
  • Beware of “surprise billing” that can require you to pay for services provided by an out-of-network provider without your knowledge

Key Points:

05:05  The three ways people get health insurance coverage in the United States: through an employer, a government plan or directly from an insurance company

05:56  Total amount paid annually for insurance depends on the monthly premium, annual deductible, co-payments, co-insurance, out-of-pocket maximum, and whether you choose an in-network or out-of-network provider.

11:43  “Surprise billing” can force you to pay for an out-of-network provider you did not choose

14:54  There are many different types of healthcare plans including HMOs, PPOs, POS and EPOs 

16:44  Short-term health insurance plans are time-limited plans that do not provide the same consumer protections as plans purchased under the Affordable Care Act (ACA) 

20:26  Affordable Care Act consumer protections and coverage requirements

32:56  Medicare is federal health insurance for individuals over age 65 and those who have been receiving social security disability insurance (SSDI) for two years

37:18  Supplemental Medigap plans cover out-of-pocket expenses not covered by Medicare Parts A and B

39:54  Medicaid is federal health insurance offered to certain people with a low or no income

43:05  Financial assistance and cost-sharing when buying insurance through the Affordable Care Act

50:02  How to choose the right health care plan for you 

This presentation was made at the BMT InfoNet 2018 Celebrating a Second Chance at Life Survivorship Symposiuim

Transcript of Presentation

00:00  Introduction:  So I was asked to speak about health insurance today, in an hour, and I could probably speak to you about health insurance for days. So I wanted to actually start this session by giving you some additional resources to know, that I'm going to provide you with some key details, and point you towards some additional resources, but this is really an introduction to some of these topics and I want you to know that you don't have to remember everything that I'm going to say today, but where to go for reminders.

00:35  Description of services provided by Triage Cancer:  So Triage Cancer is a nonprofit organization that provides information on all types of cancer survivorship issues, from the point of diagnosis throughout life. And we do that in three ways. We host educational events, we host a speaker's bureau of experts in different areas of cancer survivorship, and then we provide online materials and resources. And one of the events that we host is our Triage Cancer conference series, and we do that three times a year, typically in locations where people aren't hosting national conferences. So this year we'll be in Ypsilanti, Michigan and Reno, Nevada and Lewiston, Maine, but we do provide travel assistance grants for patients and survivors, so if that's something that you're interested in.

And then we also provide a webinar series on a variety of cancer survivorship topics, which you can watch live, or you can watch recordings of on our website. We also provide educational materials on a variety of topics, many of which I'm going to talk about today. I've brought some samples of those in the back.  We have quick guides, we have checklists on variety of topics, and then we also have local, national, international resources on our website, as well, on many of the topics we're going to talk about today.

Because where you live matters, we also have a chart of state laws that talk about what might be available to you in the areas of employment, disability insurance, leave, health insurance topics. So just out of curiosity, what states are here today? Texas, Montana, Utah, California, Idaho, Missouri, Colorado, Wisconsin, Florida. Really? So the whole country. So I will make sure to point to where there are some differences in what is available based on where you live, but we have this resource as well.

And then, because some of these topics are not the most exciting topics to talk about, like health insurance coverage, we also have a series of animated videos, they're short, that kind of give you key pieces of information related to some of these topics.

02:50 provides information about managing financial issues pertinent to you:  We also host another website called, and this is an educational website on topics related to a variety of issues that have an impact on finances, and then provide financial assistance resources. But what's different about this site is that you can go on and pick a topic and then answer questions that are specific to you, and then the information gets tailored based on how you've answered the questions. So you really get information that's specific to you. If you wanted to read it all, you could do that, but it helps kind of sort through some of the information.

03:29  Educational blog from Triage Cancer provides up-to-date information on health insurance:  Now, particularly with health insurance, but in many areas of cancer survivorship, things are constantly changing. And so one of the places where we are sharing that information is on our educational blog, so we talk about substantive cancer survivorship topics, but we also really share a lot about late breaking news and over the last year, a lot of it has focused around health insurance because there've been so many changes and right now, almost weekly we're putting out a post around what's happening at the state level because so many states are making changes to the arena of health insurance, that really have an impact on all of us. So we have the blog, but we also have our monthly newsletter, and I brought a sign-up sheet if you are interested in that as well.

04:13  Health insurance is a confusing issue due to so many industries, regulations and different laws in different states:  So delving into health insurance, I've been doing this work for about 24 years and I feel like I can say that there is no one who is an expert in every area of our health care system because there are so many industries, and so many regulations, and so many different laws that have an impact on our health care system that really no one can be an expert in all of it. And so, I have said that, anecdotally, for many years, but now I have some data to back that up. Even people who get health insurance coverage through their employers don't really understand what coverage they have, or even what they pay for it, or how to file a claim, or what their deductible is. And so if you feel like you don't have a good grasp of your health insurance coverage, you are certainly not alone.

05:05  The three ways people get health insurance coverage in the United States are through an employer, government plan or directly from an insurance company:  So I want to start by talking through some basics of health insurance coverage that are very important for you to understand, regardless of where you get your health insurance coverage. And then in the United States that only happens in three ways. We either get our coverage directly from an insurance company, we get it through our employer, or we get it from the government. And this triangle sort of roughly represents the breakdown of how it looks in the United States. Still about 50 percent of people get their health insurance coverage through their employer in the U.S., and then about another 30 percent get it through the government, and by that I mean Medicare, Medicaid, veterans’ health plans, state high risk pools, or other local options. And then really a very small portion of the population is getting their coverage through individual health insurance, directly from an insurance company.

05:56  Monthly premiums are what we pay each month for health insurance, regardless of whether or not we use it:  Now again, regardless of the type of coverage that you have, there's some important things that you need to know about your coverage. And these are terms that not only am I going to use throughout the presentation, but they're things that you need to know. So the first is what you pay for your coverage. And that's typically referred to as our monthly premium. It's what we pay each month just to have coverage. If you've never gotten medical care during the year, you would still have to pay your monthly premium.

06:22  Most health insurance plans have an annual deductible in additional to monthly premium payments:   But then there are costs that we pay when we get certain types of medical care. And the first is our annual deductible. It's what we pay out of pocket first, before our health insurance coverage kicks in. And it's a fixed dollar amount. So you might have a $500 deductible, you might have a $0 deductible or you might have a $5,000 deductible, depending on the type of coverage that you have.

06:43  Co-payments are a fixed dollar amount you pay in addition to your premium and annual deductible when you get a certain type of medical careAnd then there's something called a copayment and this is also a fixed dollar amount that you pay when you get certain types of medical care. So you might have a $20 copayment for an office visit, or a $50 copayment to see a specialist, or a $250 copayment if you visit the emergency room, again, depending on the type of coverage that you have.

07:04  Co-insurance is the difference between what you pay and your insurance company pays for your health care:  And that's different from coinsurance or cost share. And those are two terms that are used the same way. And it describes the difference between what an insurance company pays for our medical expenses, and what you pay for your medical expenses. So you are literally sharing the cost of your medical expenses. So if you have an 80/20 plan, the insurance company's going to pay 80 percent, and you're responsible for 20 percent. Now Medicare is an example of an 80/20 plan. It could be 60/40, or 70/30, or 90/10. Again, depending on the type of plan that you have.

07:41  Out-of-pocket maximum is the maximum amount you have to pay for health insurance in a given year  And then there's something called an out of pocket maximum and this is a fixed dollar amount depending on the type of coverage that you have, that is the most that you're going to pay out of pocket for your medical expenses during the year.

So, you could have a $2,000 out of pocket maximum. Or You could have a $20,000 out of pocket maximum. Or if you're on original Medicare, you could have no out of pocket maximum, but the way that you reach your out of pocket maximum is actually a math problem. So you get to add up what you pay for your deductible, plus any copayments that you make during the year, plus any coinsurance amounts that you pay during the year to help you reach that fixed dollar amount. And when you do, then your insurance kicks in at 100 percent for the rest of the year. So it's a way to understand the most that you'll pay out of pocket for your medical expenses, in a worst case scenario. But most people don't know what their out of pocket maximum is or how it works.

So, to give you an example, David has just spent a week in the hospital and he walks out with $102,000 hospital bill. But his plan has a $2,000 deductible, it's an 80/20 plan, and has a $4,000 out of pocket maximum. So assuming he's had no other medical expenses during the year, how much of that $102,000 hospital bill does he actually have to pay? Anyone?

So $4,000 because that's his out of pocket maximum, but this is how you get there. So first he's going to pay his $2,000 deductible, but then there's $100,000 left of that bill. So, the insurance company is going to pay 80 percent of that and he's responsible for 20 percent of that. But that's $20,000. So of that $20,000 bill that he's responsible for, how much does he actually have to pay? $2,000, because then at that point he'll have hit $4,000 out of pocket expenses and the insurance is going to kick in and pick up the rest. So I'm not suggesting $4,000 isn't a lot of money, but it's certainly better than having to pay the $20,000, or even $120,000 bill that he started out with. Yeah?

So the question is, which insurance picks up the balance. It's your insurance, whichever type of insurance that you have. So if you, not a supplement, it's your original insurance policy that's going to pay the rest of that bill.

With Medicare, if you have original Medicare, there is no out of pocket maximum. So if this were a Medicare example, David would actually have to pay that $20,000 bill, on top of the deductible amount. So having an out of pocket maximum and knowing what it is, is really important for your coverage. Now with Medicare there's some additional options, which I'll get to in a minute.

10:41  Whether you choose an In-network or out-of-network healthcare providers can affect your cost of healthcareSo, the other thing you need to know about your health insurance coverage is if you're going to in-network providers or out-of-network providers. Most private insurance companies have a specific group of healthcare providers that they've contracted with to provide services. Those are referred to as in-network providers. If you decide that you want to see a provider that's outside of the insurance company's network, then you might be paying more for that coverage.

So, for example, instead of it being an 80/20 plan where the insurance company is going to pay 80 percent, the insurance company might say, if you want to go out of network, you're responsible for 100 percent of that care. Some plans will say, well, it's normally an 80/20 plan, but we'll only pay 50 percent if you want to go out of network. So understanding how your plan treats in-network and out-of-network providers and the coverage that it offers, and then making sure that your providers are actually in-network, can help you reduce your costs when you go and get care.

11:43  “Surprise billing” can force you to pay for an out-of-network provider you did not choose:  So the question is, what happens when you are in a hospital and you end up seeing a provider who's out of network? Let me introduce you to surprise billing. So surprise billing is when you are in a hospital, or maybe you've gone in for surgery and you know the surgeon, you've picked the hospital because it's an in-network provider, the surgeon's in-network, and you get home after your surgery and you get a bill from the anesthesiologist, the person who puts you to sleep for your surgery, and you find out that the anesthesiologist was out-of-network. You may not even meet your anesthesiologist before surgery, and so how would you actually know that?

And so that's a good example that we were seeing a lot in the cancer community, where patients were being given surprise bills, and then you're actually responsible for those out-of-network rates because you received the care. And, so, many state legislatures have tried to address this issue of surprise billing by passing laws that protect patients.

Now, I've included on the side some of the states that actually have provided comprehensive protection to protect against surprise billing. Most other states provide this protection, but only in the context of emergency rooms, so if you go to an emergency room that's out-of-network, you're going to pay in-network rates for that emergency room visit because you don't always have control over where you're going to the emergency room. So this is actually a really topical issue because we're seeing this have a huge impact on the cancer community specifically.

13:20  Balanced billing is when an out-of-network provider charges you the balance that insurance did not pay for your healthcare service:  Now, going to the news for information around health insurance is probably the worst thing that you could do because the news refers to surprise billing as something called balanced billing, and they just use that term interchangeably, but it's not the same thing.

Balanced billing is when you go to an out-of-network provider and that provider charges you the balance of what your insurance company does or doesn't pay, so they're actually just billing it all to you if the insurance company says, ‘we're not going to pay for it’. So there's a difference between those two things, where you think you're going and doing the work to make sure you're in-network and you show up with a surprise bill, versus choosing to go to an out-of-network provider and they're balanced billing you the balance of what the insurance company isn't paying for.

Now balanced billing is allowed because if you go out of network, you're responsible for that and usually you sign a piece of paper when you check in to whatever care you're about to receive saying you'll accept the responsibility for making those payments. So these are just two things to be aware of because things are constantly changing. And this is just an example of balanced billing. If your state doesn't have a law that protects against surprise billing, I will not say there's nothing you can do. I will say it's an advocacy opportunity, because the only time we get improvements in the law and protections is when the community actually says to their elected officials, this is a challenge that we're facing. You need to do something about it. And now there's plenty of models of how states are actually handling this issue.

14:54  There are many different types of healthcare plans including HMOs, PPOs, POS and EPOs:  So the other thing you need to understand about your health insurance policy is what type of coverage it is. So there are these terms, this alphabet soup of terms called HMO, and PPOs, and POS, and EPOs, and a number of other different types of plans, but these are the three most common.

15:12  What is an HMO? So HMOs or health maintenance organizations. This is managed care health insurance coverage where you're either going to a stand-alone facility where you're getting all of your care, like a Kaiser system, or you're going to a group of providers who've contracted with an insurance company like an Anthem HMO, or a Blue Shield HMO. And the thing about HMOs is they are typically less expensive, they have lower monthly premiums because of the way that they are managing care and expenses related to their company. So in that business model, they're able to offer lower premiums to patients, but typically they have a smaller network of providers that you can actually go and see for coverage. So you're getting less choice, but you're paying less.

15:59  What is a PPO?  Whereas the PPO, a preferred provider organization is the opposite. You're paying a little bit more in a monthly premium, but you're getting more choice and you have a broader network of providers that you can actually see for care.

16:12  What is an EPO?  And then there's something called an EPO, an exclusive provider organization. And an EPO is very similar to a PPO in terms of it has a broader network of providers, but it is exclusive. So this is the type of plan that will pay zero if you choose to go out-of-network. So you want to make sure that when you're making choices about your health insurance coverage, that you're taking these things into consideration depending on the type of care you think you might need and the providers that you might want to see.

16:44  Short-term health insurance plans are time-limited plans that do not provide the same consumer protections as plans purchased under the Affordable Care Act (ACA):  Now, there is one other type of health insurance coverage that I feel like I have a responsibility to talk about, and it's short-term health insurance coverage, and these are plans that were really only intended to be fillers for gaps in coverage. So, if you are moving between two jobs, it would offer you three months of coverage between the time that your employer health insurance coverage kicks in. These were actually supposed to be eliminated with the implementation of the Affordable Care Act (ACA) on January 1, 2014 because they were only supposed to be this gap filler situation.

The challenge with these plans is that they're time limited, but they also are not required to cover any of the consumer, or comply with any of the consumer protections that are in the ACA. So if you sign up for one of these plans because you're healthy and you think that you're not going to need health insurance coverage, but then get diagnosed with a serious medical condition, like a cancer diagnosis, then they don't have to renew your coverage when the time is up for that plan. They can deny you, if you have a pre-existing condition. They can exclude entire categories of care, like chemotherapy. So you think you might have coverage and then you get diagnosed with a medical condition and you find out that it actually doesn't cover any of the things you need for care related to that medical condition. So they're are very attractive to consumers because they're relatively cheap. But then when you go to use the coverage, you find out that it's actually really inadequate coverage.

These plans are really scary to me because I get the calls from patients saying, ‘I have this health insurance plan and now it's not covering anything. What do I do?’ And you have very limited options because it doesn't create an opportunity for you to go buy a plan in the marketplace because it's not actually creditable coverage. So, this is actually a huge problem in the cancer community.

It's also becoming more of a problem because the current presidential administration is now allowing these plans to actually go up to 364 days, which also seems attractive because they last longer. If they were 365 days, then they would actually have to comply with the consumer protections in the ACA. So that's why they're only allowed to be up to 364 days. So many states are actually promoting these plans as alternatives to marketplace plans, but consumers are ending up caught having very inadequate coverage if they get diagnosed with a serious medical condition. Because if it ends in the middle of the year,  and you're not during open enrollment for a marketplace plan, you would have to wait until the open enrollment for the marketplace and then the coverage wouldn't start until January first of the next year. So, it leaves someone effectively uninsured for the rest of the year.

And we're seeing that happen with patients who are in the middle of chemo and then their plan ends because it's the end of the three months and then they can't get any other type of coverage. So it actually, that was why these plans were supposed to be eliminated because the marketplace was supposed to be a substitution for it. So I just want everybody to be aware of these plans because they're not obvious. So you know, they've got names like American Liberty Health Insurance Coverage, like they sound fantastic, but they're not coming out and saying this is a short-term health insurance plan. So as you're shopping for coverage, if you're not going through the marketplace and you're going to a private insurance broker, you just want to be conscious of this issue.

20:26  Affordable Care Act:  So speaking of the ACA, the full name of the ACA is the Patient Protection and Affordable Care Act.  I refer to it as the ACA because that's a long name, but it also is referred to as the Affordable Care Act, or Obama Care, or just plain healthcare reform. Any of those terms mean the same thing, it's frankly caused a lot of confusion for people. But I do want to just talk about a couple of the things that are in the ACA that have provided some protection in the cancer community specifically.

20:54  All health plans sold under the Affordable Care Act (ACA) must provide 10 categories of care:  The first being is that it established a baseline so that every plan sold has to at least provide this 10 categories of care, which are referred to as essential health benefits, to protect consumers from exactly that situation that I was talking about for short term health insurance plans. So you don't buy a plan and then find out, oh, it doesn't cover hospitalization, or it doesn't cover prescription drugs, or it doesn't cover mental health care, or preventive services. Every plan has to provide these services, except for those short term health insurance plans.

21:30  Affordable Care Act (ACA) plans cannot limit benefits annually or for a life-time:  Now it also provided some consumer protections that have an effect on cost of care. The first being that plans cannot have lifetime or annual limits anymore, and even though this particular provision has been in effect now since 2010, we still see insurance companies try to get around this. So it's important for you to be aware that if you come across a plan that is saying you have a cap on your benefits, they're actually not allowed to do that. So no lifetime or annual limits.

22:00  Affordable Care Act (ACA) plans cannot cancel your health insurance when you try to use it: They also can't cancel your health insurance coverage when you try to use it, what's referred to as rescissions. And this was happening so often, that many states were trying to address this at the time that the ACA was passed federally, where we found that insurance companies were paying bonuses to their employees if they could find a reason to cancel your policy. So because you were expensive to the insurance company. And so that's no longer allowed.

22:28  Affordable Care Act (ACA) allows children to remain on their parents’ healthcare policy until age 26:  The ACA also expanded coverage for young adults, allowing them to stay on their parents' health insurance coverage until they turn 26. And so this is now just based on age. Previously, young adults had to either be a full time student, or be dependent under IRS standards to stay on their parents' plan. And now it's just based on age. So even if that young adults is married, they can still stay on their parents' health insurance plan if they're under 26. 

22:55  Affordable Care Act (ACA) requires plans to cover certain preventative care at 100%:  The ACA also said we want to improve the overall health of our community. And so we want to encourage people to get preventive care, but oftentimes the co-payments that people would have to pay to get that preventive care would keep them from going and getting it, because they didn't have the money to pay out of pocket for those copays. And so now there is a specific list of preventive services where if you go and get one of those services, you don't pay a copay, you don't pay a coinsurance amount, and it doesn't get applied to your deductible. So it's totally zero out of pocket cost to you. The specific list of services is available on, but it's all the things that you would expect in an annual checkup. So cancer screenings, diabetes, blood pressure, cholesterol screenings, immunizations, flu shots, all of those things should have a zero out of pocket cost.

23:48  Affordable Care Act (ACA) requires insurers to pay for routine costs of care for patients participating in a clinical trial:  The ACA also said we want to encourage people to participate in clinical trials, so we are going to require insurance companies to cover the routine costs of care if you want to participate in a clinical trial. So previously, insurance companies would say, well, if you want to go to the clinical trial, that's great, but we're not covering anything related to that trial. You're going to have to pay out of pocket for your medical expenses’’. So the ACA says, no, you have to cover the routine costs, meaning office visits and blood work and imaging scans’’. Those would all be included in the standard of care, and so the insurance company actually has to pay for that.

 So it comes out to be almost everything except the drug or treatment or procedure that's being tested in the clinical trial.  So we actually have a lot of resources around clinical trials and insurance coverage on our website. We also participated in a series of videos that debunk some of the myths related to clinical trials. So those are available at

24:55  Affordable Care Act (ACA) provides for an outside, independent medical review process if insurance denies coverage for treatment:  Now the other thing that's ACA did to protect consumers was say that if an insurance company denies coverage for a particular treatment, or drug or procedure, if the insurance company says no and you appeal that decision inside the insurance company and they still say no, you can now go outside the insurance company to an independent medical review organization. It's also referred to as external medical review, and have them look over what your doctors are actually recommending for treatment and your medical records, and determine whether or not it's medically necessary for you to get that care.

So this sounds like one of those things that would never be worthwhile and would take a lot of time, but it actually is incredibly useful. So this stat is actually specific to California. So in California, through the Department of Managed Healthcare, 60 percent of the time, people who are appealing their denials are getting approved for their care. So just going through the process greatly increases your chances. Nationwide, the stat is 39 to 59 percent, depending on the year since it's been implemented. So it's worth actually going through the appeals process, and on our website, on the state resources page, there is the agency that does this for every state. So you can find their contact information there.

26:17  Factors the Affordable Care Act (ACA) allows health insurance plans to use when determining premiums:  Now, if there was nothing else in the Affordable Care Act, these two things alone would have been game-changing for the cancer community. And the first is called premium rating. So this is the process that the insurance companies take to decide how much to charge you for your health insurance coverage. So previously, insurance companies could look at anything they wanted to in deciding what to charge you for coverage.

Now, insurance companies can only look at four things: whether or not you're buying a policy for an individual or a family, because if you're covering more people, they can charge you more for that policy. Where you live, and it's based on your zip code, so if you live across the street from someone who is in a different zip code, they could be paying a different amount for their policy for the exact same policy than you are. They allow insurance companies to charge more for age, but they put a cap on how much more people can be charged, and they implemented a three to one ratio, meaning that someone who is 64 can only be charged up to three times more what someone who is 21 is being charged for that exact same policy. And previously, there was no cap. As you got older, insurance companies could charge us whatever they wanted to. And then tobacco use. So if you use tobacco, you can actually be charged more for health insurance coverage, but a few states have actually passed state laws that say, we're not actually going to look at that. So California, Connecticut, and DC would be examples of that.

ACA-GenderChrgs:      27:48   The second thing that the ACA, well let me ask you this, what's missing from that list? Previous health conditions, current pre-existing conditions, what else? It applies to at least half the people in the room. Gender, so women have always paid more for health insurance coverage than men, and that's no longer allowed under the ACA.

28:14  Under the Affordable Care Act (ACA) health insurers cannot deny you coverage due to a pre-existing condition:  So then the ACA went one step further and said that if you have a pre-existing condition, and apply for health insurance coverage, an insurance company can no longer deny you coverage based on your preexisting condition, or your age, or your gender, or where you live, or any other reason that they wanted to come up with, as long as you can pay for that coverage.

So these two provisions together are really what the true pre-existing protection is. Meaning that an insurance company can't deny you health insurance coverage if you have a preexisting condition, and they can't charge you more because of it. In the conversations around repealing the ACA over the last year or so, most of the attention in the advocacy community has been on keeping the second piece, but the first piece is equally important and they really have to go together. Because just telling me that I can go buy a health insurance plan with a pre-existing condition, is only half the protection. If I can't afford the policy, it's actually not really a protection at all. So having these two pieces together are what made it effective, in terms of increasing access to care for people with pre-existing conditions under the ACA.

29:26  Attempts by Idaho, Iowa and Kentucky to allow insurers to deny coverage based on pre-existing conditions :  Now there's this note in red here on the bottom about Idaho and the Iowa Farm Bureau. So in Idaho, about a month ago now, the governor decided that he was going to allow, I've now just blanked, it's either Blue Cross or Blue Shield, to sell, it's Anthem Blue Cross, to sell health insurance policies in the state that can deny people based on their preexisting condition. In clear violation of the ACA's rule of law. So they rolled it out, Anthem came up with five plans that they were ready to offer, and the rest of the world stopped and looked to see what the Department of Health and Human Services was going to do, because if they allow this to happen, it would be in clear violation of the law and what does that mean about law? So it turns out that HHS, a couple of weeks ago, came back and said, we're not going to allow you to sell these plans.

So Iowa, noted what happened in Idaho, and said we're going to do it a little bit differently. The Iowa Farm Bureau in Iowa allows health plans to be sold through this membership association, and simply by not calling it health insurance coverage, they don't have to comply with any of the consumer protections that are required under the ACA. So they're now going to roll out plans, under the Iowa Farm Bureau, that can deny you based on your pre-existing condition, can charge you more, and cut out categories of care, and have annual and lifetime limits on plans.

Interestingly enough, Kentucky had already been doing this for a number of years, the Kentucky Farm Bureau. So I mention this because the whole landscape is changing and states are doing things that are kind of under the radar, and only kind of healthcare policy wonks like me are actually paying attention to, but it's important because if we start rolling back some of these protections at the state level, the ones that are available at the federal level stop being important, and so it's something just to keep an eye on.

31:36  Affordable Care Act requires consumers to have health insurance:  Now the ACA didn't just create some consumer protections, it also created some consumer requirements, the first being that you actually have to have health insurance coverage. Now, if you don't want to have health insurance coverage, you pay a penalty. And this year the penalty is $695, or two and a half percent of your household income, whichever is more. So that could be a big difference between those two. Many people think that the individual mandate, which is what this is called, has been repealed. It has not been repealed. A law still exists, there's still a requirement that you have health insurance coverage. Starting in 2019, the penalty for not having coverage drops to zero, so effectively, there will no longer be a penalty, but the law still exists. But many people think it started this year, you still have to have coverage for 2018. This doesn't actually start until 2019, but if you wanted to not have health insurance coverage, there's a number of exceptions to the rule, so we've included a link on the slides to all of the exceptions. HHS actually just came out, about last week and created four new exceptions, that we have just written a blog about which we'll post this week.

32:56  Medicare is federal health insurance for individuals over age 65 and those who have been receiving social security disability insurance (SSDI) for two yearsNow if Medicare is how you get access to your health insurance coverage, or maybe have a family member who needs access to Medicare, it is one of the two federal health insurance programs that provides health insurance to specific groups of people, primarily individuals who are over the age of 65 and eligible for social security retirement benefits. But it's also eligible, also available, excuse me, for any individuals who've been receiving social security disability insurance, which is SSDI, for at least two years. So once you've been receiving SSI for two years, you become eligible for Medicare. It's also an automatic qualifying, or individuals who have end-stage renal disease or ALS automatically qualify for Medicare.

Now I haven't always been able to say this, but is a pretty useful resource for information about Medicare. I will also say that there is a booklet that everyone who is on Medicare receives every year called Medicare and You. You can also access that booklet from the Medicare website and see a full version of that online.  It does provide key information that you need to know, but there are four parts to Medicare coverage.

34:11  The four parts of Medicare coverage:  So there's part A, which provides hospitalization coverage. There is part B which provides medical insurance, which is covering almost everything except hospitalization and prescription drugs, which are covered under Medicare part D, as in dog. Medicare part C is Medicare-managed care. So instead of going through original Medicare A, B, and then getting prescription drug coverage through D, you're actually choosing to get your Medicare coverage through a managed care plan. So I'm very briefly going over the parts of Medicare because what I'm about to tell you will make a difference, but if you want a more in-depth look at Medicare, we have a webinar on our website that you can learn more about.

35:01  Affordable Care Act (ACA) closed the Medicare Part D “donut-hole” (gap in coverage) for prescription drugs:  But the ACA did some things to change Medicare. So, it added a free annual wellness visit, it added access to free preventive services the same way that it did under private health insurance coverage, but it also closes the Medicare part D prescription drug donut hole.

So how many of you have ever heard of the donut hole? So the donut hole is a gap in coverage. So if you have a part D plan, the way that a standard plan works is that you have a deductible, and this year the deductible is $405. So, after you paid $405 in prescription drug costs, Medicare will kick in and pay 75 percent of your drugs and you will pay 25 percent until you reach $3,750 in prescription drug costs.

When you're between $3,750 and $7,508.75 in total drug costs, Medicare pays zero and you pay 100 percent. Then when you've hit that out of pocket maximum of $7,508.75 in out of pocket drug costs, Medicare will kick back in and pay 95 percent, and you pay five percent of your drugs for the rest of the year. So that hole in coverage is what's referred to as the donut hole. 

So, the ACA actually closes the donut hole, but they do it over a 10 year period of time, in true political compromise. So from 2010 to 2020, what you pay for prescription drugs when you're in the donut hole closes a little bit each year. So this was the chart for the last four years. So this year, if you were in the donut hole, you would pay 30 percent of your brand name drugs, and you'd pay 37 percent of your generic drugs. So recently, in one of the recent budgets, I can't talk now, excuse me, budget resolutions, this is what happened. They actually sped up the closing of the donut hole by one year. So next year the donut hole will be closed for Medicare part D. So, across the board, until you hit your out of pocket max for Medicare prescription drug costs, Medicare will pay 75 percent and you pay 25 percent for your drugs. 

37:18  Supplemental Medigap plans cover out-of-pocket expenses not covered by Medicare Parts A and B:  Now I mentioned earlier that Medicare part A and B together, which are referred to as original Medicare, doesn't have an out of pocket maximum. So Part B, where you're getting the majority of your care, including things like oral chemotherapy,  or other types of drugs related to cancer care, is covered under part B and there's no out of pocket maximum. So you could be faced with a $20,000 bill a month for some of your care, and there's no max that you have to pay out of pocket.

So many people choose to buy supplemental Medicare coverage, which is referred to as a Medigap plan. So, they don't make it easy for us to figure out the differences in these types of names.  Medigap plans are additional coverage that you buy, where you pay an additional monthly premium to have this coverage, but they can be very useful because they can pick up that 20 percent that the original Medicare doesn't pay. So maybe paying $200 or $300 more a month for a premium could be a lot less than paying that $20,000 bill out of pocket every month for your care.

So people buy Medigap plans to provide that coverage, and these are the different types of plans that are available. They're lettered, which is also confusing because you have Medicare parts A through D, and then you have Medigap plans A through N. So, a lot of people come to me and they're like, I have Medicare part F. I'm like, there is no such thing. That's a Medigap plan that's has F level coverage. And many people actually pick Medigap F plans because they have very significant, they have the most coverage really, available under the Medigap plans.

Now, one of the other things that Congress did recently, in making these changes, is that they eliminated Medicare part F and Medicare part C plans in 2020. So if you are about to go on Medicare, you might want to consider picking up one of these plans to pick up your additional costs because after 2020, they will no longer be available. If you're already on them, or you buy them before 2020, you can keep them, but for new Medicare enrollees you won't have access to them. Pick one of those other letters, which is really unfortunate because it provides substantial coverage, so we don't know, but 2020 is still a couple of years off and there could potentially be additional changes between now and then. So, a lot of times our response is wait and see because we don't know what it's going to look like, come 2020.

39:54  Medicaid is federal health insurance offered to certain people with a low or no income:  Now Medicaid is the other health insurance option that's offered by the federal government that's only available to individuals who have a low income level, a low resource level, or assets and meet some other category of eligibility. At least those were the only options up to January 1 of 2014, so there were these different doors into the Medicaid program and most of the time someone in the cancer community was getting access to Medicaid through that door on the left, which is referred to as the aged, blind, and disabled program, which I know is a horrible name for a program, but you could show that you have a disability under social security standards and then you would become eligible for Medicaid.

But most of the time. individuals in the cancer community, even if you had no income because you had to stop working, it was your assets that we're kicking you out of eligibility. Because if you have a cash value life insurance policy that's more than $2,000, or an IRA plan, or 401k or some other type of retirement plan that was worth more than $2,000, it would kick you out of eligibility.

So the ACA actually expanded access to the Medicaid program by creating a new door for any individual with the household income or the household income, up to 138 percent of the federal poverty level. So for an individual this year, that's $16,753. So if you make under that, then you could get access to Medicaid. There is no resource test for this, it’s just income. So it actually removed a barrier for access to care for many people in the cancer community.

 Now this was supposed to be a requirement for every state to expand access to coverage, but the Supreme Court got their hands on the Affordable Care Act and they made it voluntary for states to participate. So this is what it looks like as of today. The states on the left have chosen to expand access to coverage. The states on the right have chosen not to. The states on the right represent about three to five million people who would have gotten access to care but haven't because their states chose not to expand. Now Maine is over here in red because in November, the voters in Maine passed a state voter proposition to expand access to Medicaid. Their governor is horribly opposed to Medicaid expansion and has actually vetoed a state legislation five times and he has refused to implement. So coverage is actually supposed to start July 2, and he's done nothing to actually implement the expansion. So we are waiting to see what will happen in Maine. 

42:29  Affordable Care Act exchanges or marketplaces:  Now the second way that the ACA expanded access to care for people, or a new way to access health insurance coverage, was by the creation of the State Health Insurance Marketplaces. And these marketplaces were originally called exchanges in the law, but no one knew what an exchange was. They decided to call them marketplaces, but no one really knows what a marketplace is either. So the best way to describe it is really an insurance shopping mall. So it's one place that you can go to find all of your private health insurance options, as well as find out if you're eligible for Medicaid. But there's some benefits to actually buying plans through the marketplace.

43:05  Financial assistance and cost-sharing when buying insurance through the Affordable Care Act (ACA) marketplace:  And the first is that you may qualify for financial assistance to actually pay for your coverage, and there are two types of financial assistance. There's premium tax credits, which lower your monthly premium depending on the type of plan that you pick and your income level. So you might pick a plan that's $200 a month, but you might only pay $100 a month because you have a $100 premium tax credit. So it just knocks that amount off the monthly premium.

Cost sharing subsidies lower what you pay for your coinsurance, your copayments, and your deductibles, depending on the plan that you pick. Now, there was a lot of news over the last year around cost sharing subsidies because the way that this works is that the insurance company provides the discount to the consumer, and they're supposed to get reimbursed by the federal government. Last year, the President decided that he was no longer going to reimburse the insurance companies for providing that discount, even though they're still required to provide the discount. So many insurance companies said, well, that's not fair. We don't want to have to provide the discount if we're not going to get reimbursed, so we're just going to stop selling policies in the marketplace. So that's where you saw a number of insurance companies pull out of the marketplaces in a variety of states.

44:23  Plans purchased through the Affordable Care Act (ACA) marketplace are standardized to enable easier comparison of cost and benefitsThe other benefits of buying plans in the marketplace is that all the plans are standardized so that you can actually compare apples to apples and oranges to oranges as a consumer. So they're standardized by their cost share. So a bronze level plan is a 60/40 plan, silver's 70/30, gold is 80/20, and a platinum is a 90/10 plan.

There is a fifth level of coverage called catastrophic coverage, but it's only available to young adults under the age of 30 or people who qualify for the financial hardship exception to having to purchase health insurance coverage. I would just tell you that I rarely do I give very directive information because I'm a lawyer and I typically avoid it, but I would say that I would not recommend to anyone in my family to purchase a catastrophic plan, or frankly even a bronze level plan, because that means you're paying for 40 percent of your health care costs out of pocket. So that's significant.

Now, something I skipped on this slide was all the plans have a cap on the out of pocket maximum. So none of the plans sold in the marketplace are allowed to have an out of pocket maximum that's greater than $7,350 this year. Now that's high, but it's a lot less than what we often see through employer plans. I've seen out of pocket maximums that are 15, $20,000 on employer plans. 

45:44  Summary of who qualifies for various types of assistance when applying for health insurance through the Affordable Care Act marketplace:  So this is what it looks like if you're visual. So if you have a household income up to 138 percent of the federal poverty level, you have access to Medicaid, if your state expanded. If you're between 138 and 250 percent of the federal poverty level, you have access to both the premium tax credits and the cost sharing subsidies. If you're between 250 and 400 percent of the federal poverty level, you just have access to the premium tax credits. If your household income is over 400 percent, you can still buy a marketplace plan, you just don't qualify for financial assistance.

46:19  You can enroll in an Affordable Care Act marketplace plan online or by phone:  Now, I often refer to the marketplace as something that's only available online, but it's not. You can call and get walked through your options. You can fill out a paper application if you want to, but there are also people who have been trained in your community to help you through your choices and to help you actually apply, and they're referred to as marketplace assisters. And if you go to or this direct link on the slide, you can put in your zip code and find the people in your community who've been trained to walk you through that. Now, this used to be really available. There were lots of people who are trained, but this year the budget was cut 50 percent for assisters, so I don't know how available it is in every county across the country because we've seen cuts to the program.

47:06  When you can enroll in an Affordable Care Act marketplace plan: Now I mentioned earlier that if you lost access to your coverage during the year, you would have to wait until an open enrollment period to actually apply for a marketplace plan. But people know that life does not just happen during open enrollment periods. So if you lose access to your employer-sponsored coverage, or your COBRA ends, or you move states, or you're otherwise losing access to your health insurance coverage, it creates a special enrollment period of 60 days to buy a plan in the marketplace, unless you have one of those short term health insurance plans because that will not trigger a special enrollment period when that plan ends. And that's why those plans are dangerous.

So, I included last year's open enrollment dates just to show you that some states that run their own marketplaces do change their open enrollment periods. We actually do not know yet when the open enrollment period is going to be for 2019 plans, so stay tuned. If you don't have health insurance coverage and you are beyond that 60 day window that would have triggered a special enrollment, then you would have to wait for the open enrollment period. Now open enrollment has traditionally been in the fall, but even if open enrollment begins November 1 and you sign up on November 1, your coverage won't start till January 1 because they're calendar year plans. So it's important to take that into consideration, if you are eligible for a special enrollment period, that you don't waste it because then it might be a long time before your new coverage would actually begin if you waited for open enrollment.

48:44  Open enrollment periods for health insurance plans not obtained through the Affordable Care Act (ACA) marketplaceOutside the marketplace rules are a little bit different. Sorry, that was my timer for myself.

So you could potentially get a plan outside of the marketplace, outside of the open enrollment periods for the marketplace, but you wouldn't have access to some of the protections that are available in the marketplace, like the financial assistance and the cap on out of pocket maximums. Some of the — there are lots of ACA protections and I've just given you a highlight of some of them — what I'm saying is that to buy the plan, you would not qualify for financial assistance if you bought the plan outside the marketplace. You might be able to find the exact same Kaiser plan in the marketplace where you could qualify for financial assistance based on your income level. Right, that's what I'm saying. There's just some benefits to going inside, but if you were outside you could potentially find a plan. But I would also say if you go outside of the marketplace, you also want to make sure that the plans that are being offered to you are not those short-term health insurance plans.

It's questionable. We're seeing it happen, and because what's happening at the state level, the enforcement of protections that are available are disappearing, faster than we can stay on top of them frankly.

50:02 How to choose the right health care plan for you:  But I do want to talk about this one last piece before we end. So when you go to look for your health insurance options, so if you get your coverage through an employer, your employer might offer you different choices. If you're going to buy an individual health insurance plan, you might want to look at all of your choices that are available to you. If you are becoming eligible for Medicare, each year you can make choices in Medicare about the different options that are available to you.

I strongly suggest that you investigate all of your options before making those choices. And this is a key tip on how to actually do that. This tip I'm going to use as a marketplace example, but you can use it if you're comparing two marketplace plans, if you're comparing two employer plans, if you're comparing your employer plan to the marketplace, because sometimes the marketplace is better than what your employer is offering you, and to compare your Medicare plan choices.

50:56  Compare total plan costsSo in this example, I've chosen the cheapest bronze level plan available to this individual, imaginary individual, a silver plan in the middle, and the most expensive gold plan available. So you can see on the silver level plan, it's $120 a month, but has a $6,500 deductible and a $7,150 out of pocket maximum, which is very high.

The gold level plan is another $130 a month at $250, but has a $2,800 deductible and a $5,700 out of pocket maximum. The gold level plan is another $140 more, at $392 a month, but has a $1,000 deductible and a $2,500 out of pocket maximum.

So just by looking at these plan options, can you tell which is actually going to be the least expensive, assuming that you're going to hit your out of pocket maximum during the year. Because when we're talking about cancer care, chances are you're going to hit your out of pocket maximum during the year. So can you just tell by looking at them, which is going to be cheapest?

I cannot. I'm bad at math, so I actually have to do it. So the way that you do it is you actually take the  monthly premium and you multiply it by 12, and that gives you your cost for having the health insurance coverage for the year, and then you add that to the out of pocket maximum, because that's the most that you're going to pay out of pocket for your medical expenses during the year. So then which plan of these three options actually ends up being cheapest? The gold level plan at $7,200 in total costs for the year. So that's, you know, a solid $1,500 cheaper than the silver level plan in the middle.

Now I do this all over the country with all different examples. This one just happens to be from West Virginia, and it's never the same. It is never, ever the same. Sometimes the bronze level plan is cheapest, sometimes the platinum plan is. The key is that you actually have to do the math. Once you've narrowed down your choices, whether it's the plans that your employer is offering you, or the plans that you're looking at in the marketplace, or Medicare, you have to actually do this math to figure out what your total cost is going to be over the year.  Because many people just look at the monthly premium and they get sticker shock when they see that $392 a month, but ultimately, by the end of the year, it's going to save them $1,500 in costs. And so when we talk about cost of care and financial toxicity, this is the one of the ways that we can address it, by making sure that people have the right type of health insurance coverage for them to reduce those out of pocket costs. I'm still not saying $7,200 isn't a lot of money, but it is certainly less, and if there are ways that we can reduce those out of pocket costs, that would be a goal.

53:43  Check to be sure your doctors and your prescription drugs are covered by the plans you are looking atBut it isn't just about cost. You also have to then check to make sure your providers are actually covered by the plans that you're looking at. And the same thing with your prescription drugs because if you don't check, your plan is going to be totally useless to you.

So the marketplace actually gives us a way to do that. So what this arrow is pointing to is that once you've actually picked the plan that you're looking at, you can click on the link that shows you the provider directory and the prescription drugs that are covered by that plan.

Now I'm going to say that this is not always right, information changes, so it's worth double checking with your providers and making sure that your drugs are actually covered by the plan by going directly to the plan, but at least it gets us more information as consumers to make educated choices. So this is just an example to show you how you can also do this comparison with employer options.

54:37  Contact information for Triage Cancer:  And then this is our contact information. So we have a variety of resources related to health insurance. There's an entire module on for health insurance coverage as well, and we have a number of webinars that go into a deeper dive into all of these topics.

54:55  Discussion about how to avoid surprise billing:  Hi, I have a question about surprise billing. So it's not, is the law saying that it's only an ER settings or it's only, typically, that's the first part.

Ms. Morales:  Depends on the state you live in.

Audience member:  So does it depend on the state you live in, the state you get care in or the state where your employer policy is sort based?

Ms. Morales:  Great question and it all depends.

So. typically, state-based health insurance coverage rules apply to insurance companies that are doing business in that state. There are some exceptions to that rule, and certainly if you have a self-insured employer where the employer actually doesn't buy a health insurance plan, but they provide for the care and direct the cost of care directly for their employees. And state-specific laws actually don't apply to self-insured plans, only federal laws can regulate those under a law called ERISA.

So, the challenge with that is that states want to provide additional consumer protections, but they don't always apply to those self-insured plans. So you want to make sure that you have a plan that isn't self-insured, and find out how the state laws actually apply specifically to your employer plan, and you can do that by calling the plan directly and asking ‘is this a self-insured plan?’

Audience member:  Like what's the action when you find yourself in that surprise billing situation for like lab work, regular lab work that you're getting every month, or MRD testing, part of your bone marrow biopsy. So you're not selecting the person who's doing your lab work and you're in an in-network provider, and they're sending it somewhere else.

Ms Morales:  Lab work is a perfect example of where you can advocate for yourself. So if you know that you're getting your blood drawn, you can ask the question where, which lab are you sending my blood to? And is it in-network? I want you to check right now to make sure that the lab that you're sending it to is in-network.

So I have a colleague who was getting her blood drawn and she happened to ask the question and they're like,’ oh, we just picked the lab that was like next up on our list because we rotate through labs’, so they weren't really checking to make sure, it wasn't in that workflow for that particular patient. So the doctor's office, so they just had like preprinted labels for labs and they just picked one and sent it off. So you can actually be proactive. It puts more burden on you to have to be checking, but it can greatly decrease what you're paying for your care. 

Audience member:   And that's at the point that you're having the labs drawn or when you're, I guess, do you have the conversation with the scheduler or the nurse?

Ms. Morales:  Really whoever handles sort of billing in the office. If the phlebotomist just happens to be the person standing in front of you when you think of asking the question, ask them and then follow up with the person, someone at the desk to say, ‘you know, I have this question about where you're sending my lab work to. Can we verify that it's actually going to an in-network lab?’


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