Finances 101: A Toolkit for Young Adults with Cancer (Health Insurance)

Mouth sores, hair loss, scars and fatigue are common side effects of cancer treatment. Financial toxicity should not be one of them, too.

Finances 101: A Toolkit for Young Adults with Cancer is a collaboration with Triage Cancer, to help young adults face head on the financial challenges – finding affordable health insurance, dealing with medical bills, managing student loans and other debt, and more – most common within this population. It’s our goal to help young adults make informed decisions so that recovering financially from cancer doesn’t become a lifelong process.

First up? Health insurance. Based on the thousands of applications and stories we’ve read, and all of the questions we’ve been asked, it’s clear that finding, affording and understanding health insurance is a universal concern within the young adult community.

You asked, we answered. Below are two of the most common questions we’ve received, with answers provided by the experts at Triage Cancer.
1. I was a graduate student when I was diagnosed, and couldn’t leave school because then my insurance coverage would have ended. I was 26 years old after the Affordable Care Act stated that you could be covered under your parents insurance until the age of 26. What happens to those of us who are in “limbo”?

Unfortunately, this is a common issue for many young adults. Prior to the Affordable Care Act (ACA), the only option was to stay in school full time in order to stay on your parent’s health insurance policy. Now, young adults up to the age of 26 can stay on their parent’s policy until they turn 26 – even if they have jobs, live on their own, or are married! But what happens if you are older than 26? One option is to shop for new insurance in your state’s health insurance marketplace. This is private insurance through independent companies like Humana or Blue Cross Blue Shield (in other words, it’s not government insurance). One of the benefits 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 will depend on your state. Prior to the ACA, the way to be eligible for Medicaid was to have low income and asset levels and fall into another category (e.g., disability, senior, pregnant, minor child, etc.). As of January 1, 2014, some states have opted to expand their programs to allow anyone who has an income up to 138% of the federal poverty level (FPL) – even if they don’t fall into another category as well. In 2014, 138% of the FPL is $16,105 for an individual. The bad news is that many states chose not to expand their programs, leaving many people with low incomes without an option for health insurance. For more information about Medicaid Expansion and where each state currently stands, visit http://triagecancer.org/health-care-reform.

2. Exactly how do co-pays, deductibles and out-of-pocket maximums work? My out- of- pocket max was $2,500, but I had to pay thousands more than that. Why?

Understanding health insurance is very much about learning a new language. So, let’s start with some basic terms:

  • Premium: The amount you pay monthly just to have health insurance coverage. You will pay this amount whether or not you go to the doctor.
  • Deductible: The amount that you have to pay for your health care before the health insurance or plan begins to pay for covered expenses. For example, if Rachel’s deductible is $1,000, her plan won’t pay anything until she has paid $1,000 for covered health care services subject to the deductible. This is also referred to as “meeting the deductible.” However, it is important to note that deductibles may not apply to all services (e.g., some preventative services will be covered at 100% even if you have not met the deductible).
  • Coinsurance or Cost-Share: This is the share of the costs between the health insurance company and you. This amount will depend on the plan that you choose. If you purchase a plan in you state’s health insurance marketplace, there are four categories to choose from based on cost-share. For example, the lowest level of coverage is the bronze plan, which has a cost share of 60%/40%. This means that once you meet your deductible, your plan is responsible for paying 60% of your health care costs, and you are responsible for 40%.
  • Co-Payment (aka: co-pay): A fixed amount you are responsible for paying for a covered health care service, usually when you receive the service (e.g., visit the doctor or receive a prescription drug). The amount can vary by the type of covered health care service and can be anywhere from $5 to $150.
  • Out-of-Pocket Maximum: Is the most that you are responsible for paying out-of-pocket during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, and copayments.

Now, how do these things all work together? Expect to pay your premium monthly no matter what – this amount will not change during the plan year. Also, if you are in treatment you can generally expect to pay your entire deductible. The hard thing to anticipate ahead of time is how much you will spend on your cost-share and co-pays for the year. But as long as you are using in-network providers and getting covered services, you cannot be charged more than your out-of-pocket maximum.

Unfortunately, however, what often happens is that people end up needing to see a provider that is out-of-network or need a service that is not covered by their insurance (e.g., many insurance companies will not cover certain genetic tests). Since out-of-pocket limits do not have to count premiums, amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits, you may end up spending more than your out-of-pocket maximum. One way to avoid this is to check ahead of time, to the extent possible, that all of the providers you are seeing are in your network. Also, double check that services you are getting do not need to be pre-authorized. To do this, call your insurance company before you receive the treatment or care and work with your healthcare team to get the information you need. And finally, you may need to appeal an insurance company’s decision not to cover a particular service. For tools on appealing a health insurance company’s decision, visit http://triagecancer.org/resources.

Have feedback or comments? Feel free to email us at toolkit@thesamfund.org.

© Triage Cancer 2014. 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.