Breast cancer awareness from the health insurance perspective

BY IRENE CARD AND BETSY CHANDLER

NEWJERSEYNEWSROOM.COM

YOUR HEALTH INSURANCE

No one (including men, although breast cancer in men is still considered quite rare) seems to be immune from breast cancer. You don't need to have a family history of breast cancer; it can hit most anyone. If you are not a breast cancer survivor, chances are you know someone who has had breast cancer (a survivor) or who is currently being treated for breast cancer. This article may be of help to them. While most insurance issues pertain to any diagnosis, there are some issues that are unique to women with breast cancer.

I cannot emphasize enough how important routine mammograms are. Many health insurance plans will cover a routine mammogram at 100% reimbursement. Routine means exactly what it says — routine. If you have a problem, like finding a lump, that is not routine and will be paid according to the terms of your insurance contract. Do not procrastinate with scheduling your routine mammograms... it can save your life!

Will wigs be covered by your insurance if you lose your hair during chemotherapy? The answer depends on your health insurance plan; some will pay for a wig each year and some plans do not cover them at all. Medicare will pay for one per year. Whether you have Medicare, individual coverage or group (through your employer), all plans require a prescription from your physician.

The Women's Health and Cancer Rights Act of 1998 was enacted by the federal government and mandates certain health coverage for breast reconstructive surgery in any health insurance plan that provides medical and surgical benefits for mastectomies. If your insurance plan provides medical and surgical benefits for mastectomies, and if you are receiving benefits in connection with a mastectomy and elect to have breast reconstruction along with that mastectomy, your insurance plan must provide, in a manner determined in consultation with the attending physician and the patients, coverage for the following: 1) Reconstruction of the breast on which the mastectomy was performed; 2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3), prostheses and physical complications at all stages of the mastectomy, including lymphedemas. Benefits will be provided to the same extent as for any other illness under your coverage, subject to the deductible and the coinsurance. For example, if your plan pays 80% after a $500 deductible, the reconstruction will be paid at 80% after the deductible.

It should be noted that the The Women's Health and Cancer Rights Act of 1998 is a mandate and self-funded plans are exempt from mandates. This means if your insurance coverage is through a self-funded plan, the employer has the final decision as to whether or not they will include this benefit in the employer-sponsored self-funded coverage.

New Jersey has a mandate that expenses related to experimental treatment must be covered the same as for any other illness. (When a person is receiving experimental treatment, the drugs are usually provided at no cost from National Institute of Health) but there are many other expenses related to receiving experimental treatment. Again, self-funded plans do not have to provide this benefit. They can, but by law, they are not required to.

Genetic testing is recommended for some women who are at high risk for developing breast cancer. The testing will determine if a woman carries the BRCA1 or BRCA2 gene which will be a strong indicator as to her chances of developing breast cancer. Not all insurance plans will pay for this test which can be quite involved and will require counseling over a period of time. The doctor must write that this person has a strong family history of breast cancer and that the results of the testing will influence medical management. You will want to contact your insurance company before you have this done to determine what will be covered and what their requirements are.

Aside from all of the above, it is extremely important that you understand how your health insurance plan works so that you follow the rules when it becomes necessary. If you are diagnosed with a potentially life-threatening illness, it is extremely difficult to concentrate on insurance rules and regulations. Does your plan require that you get a referral to get another opinion? Can you see any doctor or must you use a provider in the network? Must you call an 800 number before you are admitted to a hospital or before you go on chemotherapy? Have a family member or dear friend take charge of these details for you.

If your health insurance benefits are being continued under the COBRA law, make sure you pay your premium before the due date! A woman called me last week stating that she was busy and forgot to pay the premium on time. She was eight days late with mailing it and her coverage was cancelled. She is in the midst of receiving chemotherapy and radiation for her breast cancer and now is faced with no health insurance. In addition, more than 30 days has elapsed which means if she buys individual coverage, she will have a one year waiting period for preexisting conditions.

In closing I would like to share with you another rather profound phone conversation I had with a 35-year-old woman who is a breast cancer survivor. She lost her job and didn't "feel like" paying for COBRA. She wanted to know if it would create a problem for her to not have health insurance. I was utterly speechless! Statistically speaking, a cancer survivor has a fifty-percent greater chance of developing cancer again than the non-cancer survivor. With no health insurance, she would have a waiting period for preexisting conditions and run the risk of financial ruin. Health insurance is not a luxury; it is a necessity.

Irene Card & Betsy Chandler are both licensed insurance professionals working at MIC Insurance Services, a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.