During the time of COVID-19, people are more aware of the need for health insurance, given the additional health concerns brought about by a pandemic. In addition, those who have lost their jobs due to the economic effects of the pandemic may have also lost their health insurance.
For those with cancer, having health insurance is always important. One option that those with cancer may have but not realize is the possibility of insurance coverage from the Medicare program, a national health insurance program to which all Social Security recipients who are either over 65 years of age or permanently disabled are entitled.
If someone is under 65 and has received disability benefits from Social Security because of cancer, that individual may also qualify for Medicare. Medicare is a familiar word, but not everyone is familiar with what it means and who qualifies. Just because someone has cancer doesn't mean that he or she automatically qualifies for this program; the person needs to be disabled due to the cancer. Cancer can be considered a disability depending on the cancer and treatment. A person with cancer is disabled if it causes him or her to be unable to work for at least 12 months.
Cancer and Medicare Parts A and B
Social Security Disability Insurance (SSDI) is a long-term disability benefit program that provides wage replacement to someone who is unable to work because of a disability that is expected to last for at least 12 months. A recipient must have received SSDI benefits for at least 24 months in order to be eligible for Medicare. After receiving SSDI for 24 months, a person is automatically enrolled in Medicare Parts A and B, sometimes also referred to as Original Medicare. Medicare Part A helps cover inpatient care in hospitals, and Medicare Part B helps cover doctors' services. Part A has a deductible, and Part B has both a premium and a deductible.
There are more letters to the Medicare alphabet, however, so it is helpful to understand that just because someone becomes eligible for Medicare, that doesn't mean he or she is automatically enrolled in all parts of Medicare, or even that the individual can enroll in all parts of Medicare at any time. For example, for people with a cancer that enables them to receive SSDI benefits for 24 months, they can sign up for Medicare Parts C and D after receiving SSDI for only 21 months, and can still enroll in Medicare Parts C and D up through the 27 month. This 21-to-27 month window is called the initial enrollment period."
Medicare Part C
Medicare Part C is known as Medicare Advantage and is a health coverage option offered by private insurance companies that contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that administers the Medicare Program. Since they are private insurers, they may offer additional services to plan members that Medicare Parts A and B don't cover. Medicare Part C must cover all services that Medicare Parts A and B offer but can have different costs and rules that can affect the care one receives. It may also be a more expensive coverage than Part B coverage. While Medicare Advantage plans have a network of doctors, hospitals, and pharmacies, they may provide service only in certain geographic areas. Most but not all Medicare Part C plans include prescription drug coverage. If someone opts for a Part C plan that does not provide prescription drug coverage, that person may enroll in a separate Part D prescription drug plan, described below.
Medicare Part D
Medicare Part D is a prescription drug option also run by private insurance companies that contract with Medicare. The cost of the premium depends on the plan, and there is a deductible. Medicare Part D may help lower a person's prescription drug costs. For people with cancer, treatment may be very expensive, and a prescription drug plan may significantly lower medication expenses. A person may enroll in a Part D plan if he or she either does not have a Medicare Part C plan or his or her Part C plan does not include prescription drug coverage.
Options if an Individual Misses the Initial Enrollment Period
If someone does not enroll in a Medicare Part C and/or Part D plan during the initial enrollment period, he or she must wait until the annual open enrollment period to enroll. There are two annual enrollment periods. The first is called Open Enrollment for Medicare Advantage and Medicare prescription drug coverage. From October 15 to December 7, a person can enroll in a Part C plan with or without prescription drug coverage, enroll in a Part D plan, change his/her Part C and/or Part D plans, or withdraw from the Part C and/or Part D plans. The second annual enrollment period is called the Medicare Advantage Open Enrollment Period. From January 1 to March 31, a person may switch his or her Part C plan or withdraw from his or her plan altogether. If a person withdraws from a Part C plan during this period, he or she may join a Part D plan. During this period, a person who does not have a Part C plan may not join a Part C plan and may not join a Part D plan nor change Part D plans.
There's also a "special enrollment period" which can occur in a variety of circumstances. For instance, if someone has a Part C plan and moves outside of the geographic area where he is covered, he would be eligible for a special enrollment period where he could switch to a different Medicare Part C plan that provides insurance in the new geographic area. However, a person should avoid relying upon this option if he or she can sign up during the initial enrollment period or open enrollment. First, a person may find himself unexpectedly needing medical care but not have the proper health care coverage in place. Second, a person who is without prescription drug coverage for a continuous period of 63 or more days after his/her initial enrollment period who subsequently signs up for a Part D plan will be subject to a Part D late enrollment penalty. The longer someone is without prescription drug coverage, the larger the penalty will be.
The different parts of Medicare provide different insurance coverage, so someone with cancer should review what coverage is offered and as well as the premiums and deductibles. A plan that looks less expensive on its face may end up costing someone more in the long run.
Medicare Appeals
If Medicare does not pay for a service or item that a person has received, or if a patient is not provided a service or item that the person believes he/she is entitled to, then the individual can appeal that decision. For Original Medicare, the appeal rights are listed on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed from a company contracted with CMS that handles bills for Medicare. The notice will also advise why the bill was not paid and the appeals that a person can make. A person must file an appeal within 120 days of receiving the notice. The first step is to get the Medicare Summary Notice (MSN) that shows the item or service that the person is interested in appealing The MSN is the notice that a person receives every three months that lists the services billed to Medicare and informs the patient if Medicare paid for the services. The next step is to circle the items with which the person disagrees with on the notice and write an explanation as to why the person disagrees. In addition, a person can write an explanation of why he disagrees on a separate page and send it with the notice. The patient may ask the medical team for any information related to the bill that may help his or her case. It is important to send the notice, or a copy of the notice, to the Medicare contractor that processes claims at the address listed in the notice. Alternatively, one can appeal using CMS Form 20027, and file it with the Medicare contractor at the address listed on the notice. The form is available at www.medicare.gov/medicareonlineforms, or call 1-800-MEDICARE for a copy of the form. A person will generally get a decision from the Medicare contractor (either in a letter or an MSN) within 60 days after the contractor receives the appeal request. Medicare Part C and D programs, operated by private insurance companies, will have their own appeal rules to follow.
Author's Note to Attorneys - Giving Back by Paying it Forward
If a person with cancer is a Medicare beneficiary and has legal challenges relating to Medicare, you may be able to help by volunteering on the Professional Panel for the Cancer Legal Resource Center (CLRC). While the CLRC provides critical information and resources that help individuals deal with their problems, it does not generally provide direct legal advice or representation. Sometimes callers require legal advice or direct advocacy to resolve concerns. Thus, the CLRC is seeking members to join its Professional Panel to help people navigate their cancer-related legal concerns. Specifically, the CLRC is seeking attorneys barred in any state with experience in a wide range of specialties, including, but not limited to, employment, insurance, estate planning, government benefits, medical malpractice, consumer rights or family law. Speaking to a knowledgeable attorney can make a major difference to a person dealing with cancer. The Professional Panel member's initial commitment is a limited one: One agrees to provide a CLRC caller with a minimum of a 30-minute consultation, either in person or on the telephone. The CLRC refers these callers to attorneys or other professionals on its Professional Panel who practice in the caller's geographic area and have expertise in the area of inquiry. Any further representation, and fees charged, if any, are up to the Panel member and the referred CLRC caller. This opportunity is possible even during the pandemic, and the CLRC has a way you can use your legal skills to assist someone remotely. If interested in becoming a member of the CLRC's Professional Panel, please go to the following website: https://thedrlc.org/cancer/professional-panel-application/