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Health Insurance and Breast Cancer

    • Dealing with money matters on top of treatment can be stressful. However, taking care of your finances is another way of taking care of yourself as you move toward recovery.

    • If you have health insurance

      • Always bring your health insurance card to every doctor or medical visit.

      • Notify your insurance company according to their guidelines. For most policies, you must call to pre-certify any inpatient hospital admission. Some require an authorization for any service costing over a set amount, such as $500. Knowing your policy's guidelines and making that phone call will save you money and hassle.

      • Health insurance is like house or car insurance in that different policies cover different types of benefits. It is important to fully understand what your policy covers.

      • Be aware that some health plans may not pay for some special medical consultations. Other plans may pay for them, but you may have a higher co-pay than for a regular visit. If you have any questions, call your insurance company. Try to talk with the same person each time you call if possible.

      • Do not let your health insurance policy expire. New insurance may be difficult to obtain while you are in treatment. Pay premiums in full and mail them in plenty of time to arrive and be processed before the due date. Some policies have a grace period for late payments; however, if you require care during the grace period, any late payments may complicate authorizations.

      • Call your employee benefits administrator to request a copy of your complete insurance policy. Ask for the entire detailed benefit description, usually called a "Summary Plan Description," not a brief overview or informational brochure. This document may have a number of pages, and your employer ill give you a copy upon request.

      • Put aside some time to review your health policy line-by-line, and highlight relevant sections. Closely read any sections on exclusions and exceptions. Understand the dollar amount of your policy's "out-of-pocket maximum." If you have questions, ask your employee benefits administrator for clarification.

      • Find out how to call a "claims assistant" at your insurance company. These people can help you with accurate information if you have questions about coverage or a specific claim.

      • If you have a hard time sorting out what has been paid and what has been applied to your deductible, call your insurance company's claims assistant and ask that a "Claims Summary" be mailed to you. This should list dates of service, billed amounts, how much was applied to your deductible, and how much your insurance company paid.

      • Try to establish a warm human connection when you call to talk with a claims assistant. "Thanks so much for your help," will get you further than "I'm so frustrated with this whole thing I could scream."

      • “Explanation of Benefits” (EOB) letters need special attention. Never throw them away. They include important information. An EOB may indicate a payment, a partial payment or a claim denial

      • When you receive an "Explanation of Benefits" (EOB), carefully read every line including all foot-notes. Also, read any printing on the back of the EOB. Watch for language such as, "Please contact your provider to resubmit the claim with a valid diagnostic code. If this information is not received within 90 days of your receipt of this request, please consider this claim denied." Be sure to meet these stated guidelines on time.

      • "Pre-authorization" letters also need special attention. Watch for language such s, "This authorization does not guarantee payment." Call your insurance company if you have any questions.

      • Dealing with insurance matters can be frustrating. Take things one step at a time. Take a break. Ask for help if you need it.

      • If you phone your insurance company for any reason, enter each telephone call into a insurance tracking form.

      • Write down the name, title and phone number of anyone you speak with. Note what was discussed, mailed or promised. This will help you remember the details of each call.

    • Setting up a system to manage paperwork

      • Identify a small work area and stock it with a stapler, yellow highlighter, pens, stamps, blank insurance claim forms and file folders. Setting up this space can be a good job for a friend who wants to help.

      • Remember to document, document, document. Create a "paper trail" to keep a record of telephone and mail contacts. The tracking forms at the end of this section will help.

      • Be aware that you will receive a variety of mail, such as insurance pre-authorization notifications, authorizations and bills from various sources.

      • A strategy some people find useful is to put a basket by the front door for all treatment-related envelopes. Then schedule an hour or so once a week to sit down and open each envelope. Read the material line-by-line and use your highlighter to note important information. This may be a task you can turn over to a family member or good friend.

      • As insurance "Explanation of Benefits" (EOB) forms arrive, attach the EOB to its related claim form, the original bill and any record of your own payments.

      • Write the claim number and policy number on every document. Include the procedure code if one s given.

      • If you are required to fill out a form and return it, always make a copy for your file.

      • If the document is especially important and has a deadline, hand-carry it to the post office and pay for delivery tracking, such as certified mail with the green "return receipt requested" post card or a computer-based "Delivery Confirmation" with a tracking number.

      • Submit claims for all medical expenses even if you are not sure if a particular expense is covered.

    • What to do if an insurance claim is denied

    • If a woman has health insurance and a particular claim is denied, she can take the following steps to resolve the problem:

      • In all interactions with the insurance company about a claim, keep copies of all correspondence and note the claim number and policy or procedure code on all correspondence. Also note the name of any customer service or claims representative spoken with on the telephone.

      • Call the insurance company to find out why the claim was denied. If it is still unclear, study the explanation of benefits form. In some cases, the denial may be the result of a claim being improperly documented, such as a particular service being inadvertently omitted.

      • Check the facts. Review the policy to make sure that pre-certification, authorization and other procedures required by the insurer were followed. For example, claims for prosthetic bras, implants and wigs require a copy of both the prescription and he bill.

      • Enlist a doctor's help if fees, charges or procedures are questioned. Most physicians and their staff are experienced in working with insurance companies and can help answer questions. Ask the physician to write a letter to the insurance company documenting and/or justifying the charges, and be sure to keep a copy.

      • If the claim is denied because the insurance company states that a particular treatment is experimental or under investigation, enlist a physician to provide assistance. If he/she can give the insurance company evidence that the scientific literature supports the use of a particular therapy for a particular patient, then the procedure cannot technically be labeled as experimental. To accomplish this, ask the doctor to help obtain peer review study reports and support letters from other oncologists performing the same procedure. National patient support organizations can also help.

      • Ask for a formal review of the denied claim. Often, claims that were denied initially are paid in subsequent reviews. If this fails, ask for an appeal of the review using outside oncology experts to review the medical records and claim.

      • If these steps fail to yield reimbursement for a claim that a patient and her physicians believe is justified, a final recourse would be to contact a lawyer. National patient support organizations can help identify lawyers in each state who specialize in cancer-related insurance issues.

      Information courtesy of the Susan G. Komen Breast Cancer Foundation, www.komen.orgOpens new window or 1-800- I'M AWARE® (1-800-462-9273)

    • Taxes

      • Medical costs that are not covered by insurance policies can sometimes be deductible. Tax-deductible expenses might include mileage for trips to and from medical appointments; out-of-pocket costs for treatment, prescription drugs or equipment; and the cost of meals during lengthy medical visits away from home.

      • Obtain publications related to medical deductions from the Internal Revenue Service and from the state where you file your taxes. Find out if there are special rules for people who are self-employed, have a business or domestic partner, or other special situations.

      • Publications are mailed free upon request and usually arrive within two or three weeks. You can also view them online and print them.

      • Internal Revenue Service publications are avail-able by phone at 1-800-829-1040 or online at www.irs.ustreas.govOpens new window.

      • If you file taxes in California, the California State Franchise Tax Board publications are available by phone at 1-800-338-0505 or online at www.ftb.ca.gov/formsOpens new window.

      • If you use a tax advisor or financial planner, consult with that person after your diagnosis.

      • The "Expense Tracking" form at the end of this section can be used to help document out-of-pocket expenses as you go.

    • COBRA (Consolidated Omnibus Budget Reconciliation Act)

      • If you have a group health insurance plan through an employer with 20 or more employees, this federal legislation may enable you to keep your group coverage plan in the event of job loss, reduction in work hours, transition between jobs and certain other cases. Coverage may be available for 18 months. In California, you may be able to extend this time.

      • Qualified individuals are required to pay the entire premium cost that the employer had been paying, plus a few percent. This may be quite expensive, yet is still less costly than obtaining individual insurance outside of a group plan.

      • Rules for COBRA are complex. Ask your employer for written information. You can obtain further information and a fact sheet from the U.S. Department of Labor Employee Benefits Security Administration. Call 415-975-4600 or visit www.dol.gov/dol/topic/health-plans/cobra.htmOpens new window.

    • California State Disability Insurance (SDI)

      • If you are out of work due to a non-work-related surgery or illness, you may be eligible for disability benefits. These benefits are short-term, partial compensation for wages lost while you are unable to work. They are funded through your employee payroll deductions.

      • If at all possible, plan ahead of time to use your disability benefits. This will help make things go more smoothly.

      • Discuss the length of your disability with your physicians prior to completing your disability form if possible. Consider all the factors. Think about your job responsibilities and your financial situation. Be aware that the income you receive from State Disability Insurance is usually less than what you receive from your job wages.

      • It may be possible to have partial SDI if you go back to work at reduced hours during treatment.

      • Be aware that some doctor's offices require seven to 10 working days to complete the physician’s portion of your application. It may also take two to four weeks from the time the state disability office receives your claim before the first check is issued.

      • When you apply for SDI, fill out your short section of the paperwork and hand-carry the packet to your doctor's office.

      • You can ask your doctor’s office to mail in the signed application. However, some people prefer to personally mail the paperwork to confirm timely processing and to track the date that it is received by the SDI. Make a copy for your files and mail the originals from a post office using a tracking mechanism such as those mentioned in the above section, "Setting Up a System to Manage Paperwork."

      • For further information and for claim forms, contact your employer or call SDI directly at 1-800-480-3287 (English) or 1-866-658-8846 (Spanish) or visit www.edd.ca.gov/fleclaimdi.htmOpens new window.

      • The "State Disability Tracking" form at the end of this section can be used to document telephone calls regarding your claim.

      • Under the Paid Family Leave Act, disability compensation may be extended to cover individuals who take time off of work to care for a seriously ill spouse, parent, domestic partner or other reasons. The Paid Family Leave insurance program, also known as the Family Temporary Disability Insurance program, is administered by the State Disability Insurance (SDI) program. An estimated 13 million California workers covered by the SDI program are also covered for Paid Family Leave insurance benefits. The rules are complex, so check into whether you have job protection or return rights, whether benefits are taxable, and other issues. Call 1-877-379-3819 (English) or 1-877-379-3819 (Spanish) for general program and claim information or visit www.edd.ca.gov/fleclaimpfl.htmOpens new window.

      • Disability Benefits 101 (www.disabilitybenefits101.orgOpens new window) is a knowledgeable source if you need more help understanding your benefits. This comprehensive website offers information on disability benefits, State Disability insurance, health insurance, Medi-Cal, Medicare, COBRA and a variety of additional programs administered by state, federal and private organizations. The organization's purpose "is to take a broad, customer-centered view, focusing on the linkages among programs" and how programs interact with each other, discussing them "under one roof, in plain language."

    • If you begin to feel overwhelmed about finance

      • Even in the best of healthy times, money is a difficult area for many of us. In our culture, personal money issues are not usually discussed openly with friends or family. We may feel that we are supposed to "make it" on our own and never ask for help.

      • To need help is simply part of being human. Break the silence. Ask for assistance. Take action in small but steady steps.

      • Hospitals and physician offices usually have employees who specialize in insurance claims, reimbursement and public benefits. They may be called financial counselors, case managers or financial assistance planners. Hospital social workers may be able to suggest financial options and can offer emotional support as well.

      • Seek assistance from a community volunteer, an advocacy organization, a family member or friend. See the end of this section for resources.

      • Taking Charge of Money Matters is a workshop developed by the American Cancer Society and the National Endowment for Financial Education. This two hour workshop addresses money issues that arise during or after a person's cancer treatment. Specially trained and experienced facilitators lead the workshop. Guest speakers may include insurance specialists, Social Security/Medicare/Medicaid representatives, licensed certified financial planners, hospital billing representatives, attorneys and others. To find out if Taking Charge of Money Matters is available in your community or by telephone conference, call 1-800-ACS-2345. You may want to have someone attend with you or go in your place depending on how you are feeling.

    • Getting the most from a service: What to ask

    • No matter what type of help you are looking for, the only way to find resources to fit your needs is to ask the right questions.

      When you are calling an organization for information, it is important to think about what questions you are going to ask before you call. Many people find it helpful to write out their questions in advance and take notes during the call. Another good tip is to ask the name of the person with whom you are speaking in case you have follow-up questions.

      Below are some questions you may want to consider when calling or visiting a new agency to learn how they can help you:

      • How do I apply for your services?

      • Are there eligibility requirements? What are they?

      • Is there an application process? How long will it take? What information will I need to complete the application process? Will I need anything else to get the service?

      • Do you have any other suggestions or ideas about where I can find help?

      The most important thing to remember is that you need to be willing to ask for help to receive it. Asking can be the hardest part of getting help. Cancer is a very difficult diagnosis and disease, but there are people and services that can ease your burdens and help you focus on your treatment and recovery.

      The information on "Getting the Most from a Service" was adapted with permission from CancerCare, a national nonprofit organization that provides free professional support services for people with cancer and their families. Find out more about CancerCare by calling 1–800–813–HOPE (4673) or visiting www.cancercare.orgOpens new window.