Health Insurance: A Puzzle Wrapped in an Enigma?

National Young Adult Cancer Awareness Week is an annual, community-driven opportunity to highlight the needs, issues and challenges of young adults diagnosed with cancer between the ages of 15–39 and to spread the word about the amazing work being done by patient advocates and healthcare champions on their behalf. This blog series serves to raise the profile of the issues and make it as easy as possible for supporters to add their voices to the Critical Mass community.

By Monica Bryant, Esq., COO, Triage Cancer

When a young adult hears those life-altering words “you have cancer,” likely the last thing on their minds is figuring out how they will get or keep health insurance for the rest of their lives. Some young adults have health insurance coverage through their parents, but what happens when they age out of that policy or if their parents lose their health insurance? Or what if those twenty-somethings are just starting out in their careers and have jobs that may not offer health insurance? What happens when a young adult wants to switch jobs? What if their salary won’t cover both rent and monthly prescription expenses? These circumstances, common in young adulthood, make understanding health insurance options and finding good coverage even more important. However, all too often young adults don’t have access to quality education about their options, which can leave them confused, paying too much, or completely uninsured and unable to access health care.

Figuring out health insurance options can seem incredibly challenging and typically is not high on the priority list for AYAs. And frankly, we understand. Not many people want to spend their precious time and energy figuring out health insurance. However, it’s critical for adolescents/young adults (AYAs) to make health insurance a priority because we know that health insurance status has a direct link to health outcomes. In 2007, the American Cancer Society found that uninsured individuals had significantly increased likelihoods of advanced stage diagnoses, compared to those individuals with private insurance. The Institute of Medicine has warned that failing to address employment, health insurance, and financial concerns may threaten a patient’s return to optimum health. This is especially relevant when discussing the needs of young adults, who often fall into the low-income, uninsured or underinsured populations.

Fortunately, there are new options for access to health insurance coverage thanks to the Patient Protection and Affordable Care Act (ACA). Without education about those options, young adults may be left confused, paying too much, or completely uninsured and unable to access health care. Prior to 2010, AYAs were forced to navigate a maze of acronyms and laws to try and piece together coverage. However, thanks to the Patient Protection and Affordable Care Act (ACA) things have gotten slightly less complicated. The ACA provides some new health insurance options and protections for AYAs.

The ACA gives eligible young adults the option of staying on their parent’s health insurance plan until they are 26 years old. These young adults do not have to be dependents under IRS standards, can live on their own, be married, and even have their own children! This rule gives young adults additional options and helps to bridge the gap that may occur between leaving school and finding a job that offers health insurance benefits. Thanks to this provision, there are now over 3 million more young adults with health insurance.

For those AYAs over 26, or those in situations where COBRA isn’t feasible, the ACA has made it easier for those with a cancer history to obtain insurance. As of January 1, 2014, the ACA prohibits insurance companies from denying coverage to an individual with a pre-existing condition, such as cancer. Additionally, insurance companies aren’t able to consider an individuals’ pre-existing condition when determining how much a plan will cost.

The ACA also created a new way to shop for health insurance called health insurance marketplaces. The Marketplace can help consumers compare all of their insurance options based on price, benefits, and other features that may be important to them, in plain language that makes sense.

Insurance that you can buy in the Marketplaces is private insurance from companies like Humana or Blue Cross Blue Shield (in other words, it’s not government insurance). In these Marketplaces, consumers can access multiple plan choices at varying levels of cost and benefits. All health insurance companies that sell their plans through the Marketplace must offer the following standardized plan levels, with the difference between them being the amount of money that you pay out of pocket for your healthcare costs (i.e., cost sharing).

• Platinum: plan pays 90%; you pay 10%
• Gold: plan pays 80%; you pay 20%
• Silver: plan pays 70%; you pay 30%
• Bronze: plan pays 60%; you pay 40%

Consumers should think about their health care needs and make a decision about what level of coverage would be best. Once they make that decision they can sort through the plan options to just view and compare the plans being offered at that level of coverage.

Another benefit to shopping in the Marketplaces is that you may be eligible for financial assistance, based on your income and family size. For more information, take a look at Triage Cancer’s Quick Guide to the ACA or visit healthcare.gov.

If you have very limited income, then you may be eligible for Medicaid. Eligibility standards depend on your state. Some states have opted to expand their programs to allow anyone who has an income up to 138% of the federal poverty level (FPL). In 2015, 138% of the FPL is $16,243 per year for a single person; $21,983 per year for a married couple in 2015. Other states chose not to expand their programs, leaving many people with low incomes without an option for affordable health insurance. For more information about Medicaid expansion and where each state currently stands, visit: http://triagecancer.org/health-care-reform.

For more information about all of the health insurance options available to you in your state, visit www.HealthCare.gov. Also, take a look at this blog post on AYAs and health insurance on The SAMFund’s website.

The ACA attempted to make it easier for most people to get health insurance. However, we know that choosing a health insurance policy, and using those policies effectively, can be overwhelming and stressful. But it doesn’t have to be. Here are a few tips to help you navigate health insurance.

1. Make sure you understand common health insurance terms. Don’t be embarrassed if you’ve heard these terms a lot, but still don’t totally understand them or how they all work together. You are not alone! Here are a few critical ones:

• Premium: the amount you pay monthly just to have health insurance
• Deductible: the amount you have to pay each year before your health insurance policy starts paying for your medical expenses
• Co-Pay: an amount you may have to pay each time you access certain health care services (e.g., $25 when you see the doctor, or $10 for each prescription drug)
• Cost-share: the difference between what your health insurance policy pays and what you pay for your medical expenses (e.g., 80/20 plans are ones where you are responsible for 20% of your health care costs and the plan is responsible for 80%, after you meet your deductible)
• Out-of-Pocket Maximum: the most you are responsible for paying for covered medical care each year. The deductible plus any co-pays or cost-share amounts that you pay during the year add up to help you reach your out of pocket maximum. Once you reach that amount, your insurance should pay for 100% of your covered medical expenses.

1. Make sure you understand how each plan would work in your specific health circumstances. For example, if you are in the midst of treatment, a bronze level plan (60/40 cost share) is likely not going to be appropriate. You will probably end up paying much more out of pocket, if the services are covered at all. And pay attention to whether or not your providers are covered and if plans have separate deductibles for medical services and prescription drugs.
2. The math matters! Once you have narrowed down your plan options, do the math. In order to figure out the most your medical expenses and insurance coverage could cost you during a year, multiply your monthly premium amount times 12. Then add that to the out-of-pocket maximum for that plan. Do that for each plan you are looking at and then compare the final cost amounts. Sometimes paying more for your monthly premium will cost you a lot less by the end of the year.
3. Look into possible financial assistance options available to you.
4. Know that there are places to go for help when trying to navigate health insurance:

Visit the Triage Cancer Blog to stay up to date on all of the changes in health insurance and other cancer survivorship topics!

Monica Fawzy Bryant is a cancer rights attorney, speaker, and author. She is dedicated to improving access to and availability of quality information on the practical, insurance, employment, and financial issues surrounding a cancer diagnosis. Ms. Bryant is the Chief Operating Officer for Triage Cancer, a national nonprofit organization connecting people to cancer survivorship information through a national Speakers Bureau, educational events, and online tools.

© Triage Cancer 2015. Please note that this information is designed to provide general information on the topics presented. It is provided with the understanding that the experts are not engaged in rendering any legal or professional services by its publication. The information provided should not be used as a substitute for professional services.

Originally published at criticalmass.org on April 6, 2015.