Don't Drown in Medical Debt
May 2, 2023
Presenter: Monica Fawzy Bryant, Esq. Triage Cancer
The presentation is 45 minutes long, followed by 15 minutes of Q&A
Summary: This video discusses the well-known fact that cancer is expensive, and provides tips on how to select the most cost-effective health insurance plan for you, manage medical debt, and find low-cost prescription options and financial assistance plans to help pay for medical expenses.
Financial toxicity refers to the financial burden that often occurs after a diagnosis and treatment.
Your health insurance status is the most significant contributing factor to financial toxicity.
A denial of insurance coverage can be devastating, but you do not have to take no for an answer.
(03:43): It’s very important to understand insurance basics – the definition of terms used to describe various aspects of health insurance policies.
(05:51): One of the most important things we can know about our health insurance is the amount of our potential out-of-pocket maximum.
(09:20): Surprise billing occurs when an out-of-network healthcare provider provides you service at an in-network hospital, and insurance does not fully cover the bill.
(09:59): The No Surprises Act says that if the person has done their due diligence and it is a surprise that someone ended up out-of-network, the insurance company and the provider must negotiate how the payment will happen.(11:38): Most people, annually, have an opportunity to choose which health plan they want, but it can be difficult to compare the overall cost of each plan. See tips for how to pick a plan that will minimize the chance of medical debt.
(19:44): The Explanation of Benefits document (EOB) is an estimate of what the insurance company expects to pay and what it expects the patient to pay. Medical bills from providers should not be paid before you receive the EOB from your insurance company and compare it to the bill.
(26:41): If insurance denies coverage of a medical expense, it is worth your time to appeal that denial of coverage
(37:32): Most pharmaceutical companies and specialty pharmacies have assistance programs, with different eligibility requirements, to help patients afford their prescriptions.
Transcript of Presentation:
(00:00): [Marsha Seligman]: Hello, everyone. Welcome to the workshop: Don't Drown in Debt. My name is Marsha Seligman, and I will be your moderator for this workshop.
(00:09): Speaker Introduction. It is my pleasure to introduce Monica Fawzy Bryant. Ms. Bryant is a cancer rights attorney, speaker, and author dedicated to improving access to quality information on healthcare-related issues. She is the co-founder and chief operating officer for Triage Cancer. This national nonprofit organization provides education on the practical and legal issues that may impact individuals diagnosed with cancer and their caregivers.
(00:38): Ms. Bryant is co-author of the first and only book on Cancer Rights Law and is an adjunct law professor at the University of Illinois at Chicago School of Law, teaching a class on cancer rights. Throughout her career, she has provided hundreds of educational seminars for individuals diagnosed with cancer. Please join me in welcoming Ms. Bryant.
(01:01): [Monica Fawzy Bryant]: Thank you so much for that wonderful introduction and the opportunity to spend a little time with you all talking about dealing with debt and, more specifically, medical debt. So, when we talk about a serious diagnosis like cancer, we know that debt is a very common byproduct, so to speak, of having to engage in the healthcare system. And if you are struggling with your finances, you are certainly not alone; in fact, four in 10 individuals report having medical debt, which is about 100 million adults in this country, so unfortunately, it is a very common problem.
(01:48): What is Financial Toxicity? In the cancer community, there's been a term that's been used pretty frequently lately called financial toxicity. And financial toxicity refers to the financial burden that often occurs after a diagnosis. We've been talking about financial toxicity for years, and one of the reasons it is so challenging to address is that there are multiple contributing factors to this financial burden, or toxicity, that we experience after a serious diagnosis.
(02:17): At Triage Cancer, we believe somebody's health insurance status is the most significant contributing factor to financial toxicity. Now, that could mean not having health insurance at all, but more often, it means that someone needs to have the right health insurance policy for them or be more effectively navigating that policy. And so, we have lots of resources on our website at TriageCancer.org to help people pick the right plan and navigate those plans.
(02:48): Certainly, the employment changes that occur after a serious diagnosis could impact somebody's finances, and then all the things that happen in life that may impact our finances, like relationship changes or moving. Those things continue to happen even after a serious diagnosis, further compounding the challenges.
(03:08): I'm not going to spend much time discussing health insurance today, but given that it is such a significant factor, I would be remiss if we didn't touch it. One of the reasons people struggle to find the right health insurance policy or to navigate it effectively is that reading the specifics of that policy is like learning a different language, but rarely are we ever taught that different language. We often say there should be a class in high school on health insurance and finances because we all have to deal with it, but too often, we get this crash course once there is a serious diagnosis.
(03:43): It is very important to understand Insurance Basics. Insurance Basics: So, learning the language is incredibly valuable, and these are just some of the terms that are used related to the cost. Your premium is the amount you must pay every month to have health insurance, and you will pay that amount whether you use your health insurance. For example, depending on your plan, you could have a plan with a $ 500-a-month premium or a $ 2,000-a-month premium.
(04:11): Your annual deductible is the amount you must pay each year before your health insurance kicks in. Then there are additional costs that you will incur when you go and use your health insurance. So first is your annual deductible. This is a fixed dollar amount that you have to pay each year before your health insurance kicks in. The amount of the deductible is going to depend on the plan. For example, some plans have a $0 deductible and kick in on day one; some plans have a $5,000 deductible, so you have to pay $5,000 before the insurance company kicks in.
(04:43): When the insurance company starts paying, that is referred to as your cost share or your co-insurance, so these terms mean the same thing. This is always going to be presented to you as a percentage. For example, you have an 80/20 plan, which means once you've met your deductible, the insurance company kicks in and pays 80% of your healthcare costs, and you're responsible for 20%.
(05:11): Now, there is often an additional payment called a co-payment, and people often need clarification on co-payment and co-insurance. They're actually two different things. Where co-co-insurance is a percentage, co-payments are a fixed dollar amount that you pay each time you get care. Again, these will depend on the policy; It could also depend on the service. So, it's very common to have something like a $20 co-payment when you go and see your doctor or a $30 co-payment to see a specialist or a $250 co-payment if you go to the ER, but it's always going to be that fixed dollar amount.
(05:51): One of the most important things we can know about our health insurance is the amount of our potential out-of-pocket maximum. One of the most important things we can know about our health insurance is the out-of-pocket maximum. This is a fixed dollar amount, the most we should pay out-of-pocket for our healthcare in the year. Once you meet your out-of-pocket maximum or hit your out-of-pocket maximum, the insurance company kicks in and pays 100% of your expenses for the rest of the year.
(06:20): Now, the details here do matter. Different plans have slightly different definitions of out-of-pocket maximum in terms of how you get to it. However, if, for example, you have a plan through the marketplace, the way that the out-of-pocket maximum is met is by adding up everything you pay towards your deductible, everything you pay towards your co-payments, and everything you pay towards your co-insurance. So, it's everything you're paying out-of-pocket except those monthly premiums.
(06:50): Let's use Dan as an example. Dan has a plan with a $2,000 deductible. It's an 80/20 co-insurance that has an $8,000 out-of-pocket maximum. Dan hasn't gone to the doctor at all this year, but he gets into an accident and ends up with a $102,000 hospital bill. So, what does Dan have to pay?
(07:13): The deductible is the first thing we must always pay. Dan pays $2,000, and we subtract that from the bill leaving $100,000. He's met his deductible, so now the co-insurance kicks in, and the insurance company pays 80%, and Dan pays 20%, 20% of $100,000, $20,000. But does Dan have to pay that entire $20,000? The answer is no, and the reason for that is that out-of-pocket maximum.
(07:43): So, how much does he actually have to pay? He has to pay another $6,000 because he's already paid $2,000 in the deductible. So, once he pays another $6,000, he meets that out-of-pocket maximum, and the insurance company pays the rest.
(08:01): I am not suggesting that $8,000 isn't a lot of money. Of course, it is. But when we start thinking about our expenses without these out-of-pocket maximums, it's undoubtedly better than 20,000 and certainly better than the $102,000 someone might have to pay if they were uninsured. So, understanding how all of this works is a critical component to minimizing potential medical debt.
(08:31): Another challenge is that some terms that aren't interchangeable are used interchangeably, and this is an example of that:
Balance billing is when someone chooses to go to an out-of-network provider, and the insurance company pays, let's say, 50% for an out-of-network provider. That out-of-network provider is allowed to turn around and charge the patient the other 50% because that person chose to go to an out-of-network provider.
But if they go to an in-network provider? Then that provider must accept whatever they agree to from the insurance company. They can't bill the patient for the rest of it.
(09:20): Surprise billing occurs when an out-of-network healthcare provider provides you service at an in-network hospital, and insurance does not fully cover the bill. Now, that's very different from surprise billing, which is where you do your due diligence, and you think that you have gone to an in-network hospital and seen in-network providers. Then you find out that somewhere along the way, someone wasn't in-network. And this is very common in surgery, for example, when you find out that the anesthesiologist wasn't in-network after the surgery. That is what's referred to as a surprise bill. And over the years, states have started to pass state laws to help protect patients against surprise billing.
(09:59): The good news is that as of January 1st of last year, we now have a federal law that protects patients against surprise billing called the No Surprises Act. The No Surprises Act says that if the person has done their due diligence and it is a surprise that someone ended up out-of-network, then the insurance company and the provider must negotiate how the payment will happen. It's treated as an in-network provider with respect to the patient.
(10:35): So I bring this up as a discussion around medical bills because if you receive a big bill, that is a surprise in terms of, "Wow, I thought this person was going to be in-network, and now they're telling me they're out-of-network and they're making me pay a hundred percent 100%," there are a no surprises help desk. You can call them on the 1-800 number, or you can fill out a form online, and I've given you both of those on the slides, and the No Surprises Help desk will help you figure out how to deal with this surprise bill. And even though this law is over a year old, many people still don't know about it.
(11:15): In addition to ensuring we understand our health insurance and how it all is supposed to work, we can make choices each year to minimize our future medical bills. Understanding what all of our options are is a really valuable piece of this medical debt puzzle.
(11:38): Most people, annually, have an opportunity to choose which health plan they want, but it can be difficult to compare the overall cost of each plan. Now, generally speaking, there are certain times of the year that we get to enroll in health insurance, depending on the type of health insurance somebody has. We have more information about these different enrollments for the various types of health insurance on TriageCancer.org.
(11:56): Having all these different options is fantastic, but how do we actually make choices between those options? I'm going to walk you through a quick example of how you can compare two plans sold in the marketplace, how you can compare between potentially two plans that an employer is offering, or let's say you're trying to decide, "do I take my employer plan or buy a marketplace plan?, or even if you're trying to choose between two Medicare advantage plans. The exercise I will give you works in all of these different situations.
(12:31): How to pick a plan that will minimize the chance of medical debt. Here, we have three different health insurance plans.
The first plan has a $ 200-a-month premium, a $6,000 deductible, and an $8,000 out-of-pocket maximum.
The second is a silver plan with a $275 a-month premium, a $2,500 deductible, and a $6,000 out-of-pocket maximum.
The third is a platinum plan at $400 a month with a $2,000 out-of-pocket maximum.
If I have a serious medical condition, I have a lot of medical bills, and I will hit the out-of-pocket maximum, which is the case in many circumstances you all may be in. How do I pick a plan that will cost me the least? Can I look at one of these columns? Can I look at the monthly premium?
(13:34): And the answer is no. You have to do the math, and the way you do the math is you multiply the monthly premium by 12 because that's how much you'll pay in premiums for the year. Then you add the out-of-pocket maximum. And when you do that for all three of these plans, that platinum plan ends up being significantly cheaper at the end of the year.
(14:03): The challenge with this is many people only look at that monthly premium, and they get a little bit of sticker shock thinking, "Well, why am I going to pay twice the amount at $400 a month when I can only pay $200 a month?" And the difference is the total math here. It's important for people to avoid getting that initial sticker shock from the monthly premium.
(14:27): But of course, that total cost is only one piece of the puzzle; you do also want to consider the co-payments and the deductibles because maybe two plans are very close together, and one has a $5,000 deductible, and one has a $0 deductible. That means the $0 plan kicks in on day one.
(14:51): Even if you find the most affordable plan, you need to ensure that it includes your providers and any facilities you use in their network because picking the most affordable plan that doesn't have any of your providers in it isn't going to be helpful. And the reason for that is that most of the time, the out-of-pocket maximum only includes payments made towards in-network providers.
(15:18): Similarly, you need to make sure any prescription drugs you're taking are included in that plan's formulary, which is the list of drugs that that plan will cover. I often say to people who have complex medical situations, and it's even helpful to ask providers, "Listen, I know what drugs I'm currently on, but are there any medications that you foresee I could potentially need to take in the next year?" And that's helpful because you can ensure all of those potential medications are also on the formulary.
(15:56): I know this is a lot of information quickly, so I want to point you to two specific resources.
The first is one of our animated videos, it's about five minutes long on how to pick a plan, and it goes through the example I just gave you.
The other is an actual worksheet that you can print out, and it prompts you to fill in the important information and helps you do the math to compare to plans. Both resources are available for free on TriageCancer.org.
(16:27): Even if you have the best health insurance, there will still be medical bills, so what do we do about this? Sometimes bills can even be reduced before you receive care, and the first step in this process is making sure you're communicating with your healthcare providers about costs.
(16:51): For some reason, in this country, it is not customary for us to talk about costs with our healthcare team, and we think that that needs to change because just starting the conversation makes the healthcare team aware that you are, in fact, concerned about the costs.
(17:09): Now, there may also be some other people whom you aren't currently seeing on a healthcare team that could be helpful, like a social worker, a navigator, or a financial counselor, because there may be other programs, you're eligible for at the hospital, like the ability to pay programs that provide discounts or financial assistance. So, there are some resources out there for you.
(17:31): Now, if you know, for example, that you are going to an out-of-network provider, and that happens occasionally for a number of reasons, so maybe you need surgery, and there is a surgeon that specializes in your diagnosis, but they're out-of-network, you could potentially negotiate with that provider before you even receive services.
You could ask for a payment plan.
You could ask the provider to charge you what they would've charged someone in-network, which will always be a discounted rate.
(18:07): Avoiding out-of-network charges can also include arranging independent lab work, so sometimes you might be seeing a doctor in a hospital facility, and the lab in that hospital facility isn't in your network. Well, if the doctor sends you down to that lab because it's convenient and you know it's out-of-network, then you will pay more for that lab work. Sometimes you can figure out, "Oh, well, this lab isn't in my network, but the one down the street is, so I'm going to go get my blood work done there and have the results sent to you."
(18:43): Similarly, the same idea works for other tests. If you are to get an MRI in the hospital, it is typically more expensive than if you go to a standalone MRI imaging facility. So Healthcare Bluebook is a great tool to shop around and see the estimated prices before getting those tests.
(19:07): Sometimes, it's helpful to group follow-up appointments, so you're only paying one co-payment instead of multiple co-payments. Sometimes there may be less expensive generic versions of medications or treatments. Now, I am not suggesting that someone take a less effective medication just because it's less expensive, but if you have a conversation with your healthcare team. They think that it is appropriate, that is an additional way to save money.
(19:44): The Explanation of Benefits document (EOB) is not a bill, and is incredibly important to understand and interpret. You will get many communication pieces once you receive care. So, just from the health insurance company, you could get a letter saying, "We've gotten a claim." Then you could get another communication saying, "We're processing your claim." And then, finally, you're going to get something called an explanation of benefits or an EOB, and the EOB is incredibly important to take a look at.
(20:12): This is what we think is sort of a gold star version of an EOB, and the telltale sign is somewhere in big black letters; it's going to say, "This is not a bill," because it's not a bill, it's the health insurance estimation of what you are going to be responsible for based on where you are in the year in terms of meeting your deductible and your out-of-pocket maximum.
(20:40): Some other information will be about the policyholder and who the patient is, if it's a family plan, a summary of how much was billed, how much is the health insurance company going to cover, and how much you are responsible for. Then below, there should be some detailed information with dates of the different services and what's included in this EOB (explanation of benefits).
(21:05): Now, many EOBs (explanation of benefits) do not even include words in this section, it's just this code, and you have to figure out what that code is, so that can be challenging. It should also say, "Well, how much was charged by the provider? How much is the allowed amount, which is the agreed amount that the provider and the health insurance company agreed to previously? And then how much are you responsible for based on where you are meeting your deductible and your co-insurance?" A great EOB (explanation of benefits) would also list how much you've paid for the year towards your deductible and your out-of-pocket maximum, but not every EOB (explanation of benefits) has all of this information.
(21:53): And the last piece of communication you're going to get is from the provider. So, this could be the doctor, the hospital, the lab, the imaging center. The challenge is that it doesn't always happen in this order. Providers often send people the bill faster than insurance companies at processing the claim. So it could be that you get a bill first, look at it, and go, "Oh my gosh, that's a lot of money." But if you haven't gotten the EOB (explanation of benefits) yet, you should not pay that bill yet, because what that means is that the provider is essentially billing you for the full amount; they haven't taken into consideration what the insurance company is going to pay yet. So again, the rule of thumb is to wait until you receive the EOB (explanation of benefits) before you pay any bills.
(22:50): Now, this shouldn't happen in a vacuum because if you get the bill and you think to yourself, "Well, I haven't gotten my EOB, I'm not going to pay it yet," but you never communicate that to the provider, from the provider's perspective, you're just not paying your bill. So, I recommend calling the provider and saying, "Just wanted to let you know I've gotten this bill, but I haven't gotten my EOB yet; it doesn't look like insurance has processed it. Can you please push back the due date and make a note in my file that I'm waiting on the EOB?" In many years of doing this, I have never heard of a provider having an issue with this.
(23:29): When you get that EOB (explanation of benefits) and the bill, we, as healthcare consumers, need to be checking to make sure it's accurate. Medical billing is a human process, and humans make mistakes. The last study I saw was that 80% of all medical bills contain at least one error. We need to ensure that we are being billed for everything we receive and that all the numbers are accurate. I've seen crazy stories where someone is billed for 11 surgeries instead of one because someone accidentally hit the one twice—so making sure that everything is accurate on the EOB and that the EOB and the bill match is very valuable.
(24:15): This process might feel overwhelming for someone with a complicated medical history. There are professional bill reviewers that you can hire to help you navigate this process.
(24:30): If you receive a denial from the health insurance company, know you do not have to take no for an answer. As consumers, we have the right to appeal denials from our health insurance company. Now, the details vary from plan to plan, but for somebody who has an individual plan they've purchased themselves or got through work, there will be at least two levels of appeal. In the internal appeals process, you return to the insurance company and ask them to reconsider. If they still say no, then you have the right to something called an external appeal, also known as an independent medical review, and this is where you go to an independent entity. That entity looks at the plan, looks at your medical history, looks at the claim, and makes a decision as to whether or not receiving that service was medically necessary.
(25:40): A couple of things to note here about appeals. First, if you've requested prior authorization before receiving services and have been denied, you can appeal at that start. You can also appeal if you've already received the service and been denied.
(25:59): The second piece, this is absolutely an added burden on patients and their families; it is a hassle, and it is more to add to your plate; 100% I agree with that. However, adding this to your plate and appeal denials is often worthwhile. The exact number varies based on the type of insurance, but about 40% to 60% of all appeals are decided in favor of the patient. I'm going to say that one more time. 40% to 60% of appeals are decided in favor of the patient.
(26:41): If insurance denies coverage of a medical expense, it is worth your time to appeal that denial of coverage. So, when somebody gets a denial, it is worth your while to appeal that denial. There are several hurdles in the appeals process, the least of which is that appealing a decision adds more to your already, full plate. Appealing a decision to the insurance company is a lot to handle and a lot to keep track of.
The First Hurdle in Appealing an insurance company denial - Keeping Track of Information
There could be conversations between providers, health insurance companies, and pharmacies; it is important to keep track of the following:
Every phone call, including the names of the people you talk to, the summaries, and the discussed action items.
You must send information or documentation, and if so, to whom and by when.
Are you expecting something in the mail, and if so, from whom and by when?
So, because it's a lot, we recommend something other than the post-it note method of keeping notes because inevitably, you lose that one really important post-it notes.
We have an appeals tracking form that you can download from our website to help you stay organized in keeping all of this information. It is called Health Insurance Appeal Tracking Form.
(27:39): One of the reasons I think this tracking form is really helpful is that because there are blank spaces in there, it's sort of a prompt when you're on the phone to remember, "Oh, I need to get that person's name. Oh, I need to remember to ask them when I can expect to get whatever in the mail." So, it's just a useful tool.
(27:59): This process is also a wonderful time to engage family and friends. So, that good friend of yours says, "I'm so sorry you're dealing with all of this; let me know if there's anything I can do to help." "Fantastic. Do you know what you can do to help? Sit on the phone with me, and you, please take notes while I have conversations with the insurance company and the providers." So, the first hurdle is staying organized.
The Second Hurdle in Appealing an insurance company denial - What stage of the appeals process are you currently in?
Health insurance companies use a method called peer review, where they hire a doctor to discuss the necessity of a medical service with your own doctor. While this may seem like a good idea, the challenge lies in the fact that the hired doctor may not have the same specialty as your doctor, causing a knowledge gap. Additionally, peer reviews are not the same as external appeals and are simply another level of internal appeal.
The Third Hurdle in Appealing an insurance company denial - Who has The Knowledge of Appeals?
(29:37): And finally, the last major hurdle with respect to appeals of knowledge, is not enough people know that they have the right to appeal a decision by the insurance company.
Here are some facts about claim denials and appeals in the year 2021:
Forty-eight million claims were denied in 2021
99.9% of those denied claims were never appealed
40% to 60% of all appeals are decided in favor of the patient
So, when somebody gets a denial, it is worth your while to appeal that denial
(30:29): The appeals process is vital tool to avoid medical debt. And it's so important, and it's such a soapbox issue for us; we have several free resources available on our website to help you navigate the appeals process, everything from a Quick Guide to Appeals for Employer-Sponsored & Individual Health Insurance to a short little animated video to a 90-minute-long webinar that gets into the weeds of all the things. So please, if you've received a denial, take advantage of those free resources.
(30:53): Now, if you haven't gotten a denial, but you don't have the money to pay the bills, you have to negotiate. And the key to successful negotiation is timing, so make sure that you are negotiating before the debt is sent to collection agencies because once it's sent to collection agencies, it gets much more challenging to come up with solutions. And there are several things that you could ask for, like more time or a payment plan or maybe even accepting a lower lump sum payment. This works with all different types of creditors, not just healthcare providers.
(31:38): Now, we have a little bit of good news regarding medical collection debt and how it impacts your credit score. The three major credit bureaus have recently said they will start treating medical debt differently than other debt. So once medical debt gets paid, it's no longer going to be included on your credit report, and you'll have more time to pay that medical debt before it hits your credit report. We're also anticipating an announcement any day now that says, "Debt under $500 is likely not going to be reported on credit reports anymore." So, some small good news there.
(32:21): When considering dealing with your medical debt and financial information, it's important to stay organized. There are a lot of pieces of paper, there are a lot of moving pieces, and that is not a good organizational system, so what is? It doesn't matter, file folders, three-ring binders, or electronic files; there are some pre-built planners that you can pay for that help you stay organized. The best organizational system for financial information is one that you will be able to maintain.
(32:59): Whatever makes the most sense for you in other areas of your life could be helpful for you here. And if staying organized is a challenge that you're having, we have a couple of webinars that give some very practical, easy-to-implement suggestions on how to stay organized. But specifically, with respect to medical bills, we've created a bill tracking sheet; it's a spreadsheet that could be Excel or Google Sheets or numbers, depending on the platform you use. And what's helpful about this worksheet is that you can put in information about your insurance policy, so how much is the deductible, and how much is the out-of-pocket maximum? Then as you start getting bills, you add them to the bottom, and the system spreadsheet will start deducting amounts about how much you have left to meet your deductible and how much you have left to meet your out-of-pocket maximum. So, this worksheet is particularly helpful if you have an insurance company that doesn't have a great EOB and keeps track of this for you.
(34:14): Keep track of your medical expenses, as they could be tax deductible. One of the reasons it's so valuable to keep track of all those expenses is that some could be tax-deductible. Of course, we just closed tax time for this year, but if you haven't filed your taxes yet, you could still get an extension. If you struggle to figure out how to file your taxes, several free resources will help you, including the Volunteer Income Tax Assistance program.
(34:51): Now, when we're talking about dealing with medical debt, creating a budget, and making sure that you're allocating the right amount of money to pay that debt down is helpful, but creating a budget is one of many things that I say that is easier said than done. And so there are some organizations out there that provide free help. Credit counseling agencies are a great solution, and there is a National Foundation for Credit Counseling where you can put in your ZIP Code and find someone local to you.
(35:27): Also, financial planners can be very helpful. There is a misconception that financial planners are only helpful if you have a ton of money when in reality, many financial planners help people who might be considered middle-income. However, I don't know what that means anymore. It helps them not experience huge amounts of debt or challenges with their credit.
(35:57): Financial planners charge in all different ways. Sometimes they are hourly; sometimes, it's on a contingency basis. Sometimes, they're free because they hope you'll buy another service. So, the Financial Planning Association is a good place to start looking for financial planners.
(36:18): Sometimes there isn't enough money to go around, and you need additional help, and that's where I point you to financial assistance. Our website at cancerfinances.org has a module on financial assistance options. In that module, there will be local, state, and county organizations; cancer healthcare organizations with different financial assistance programs; and private programs that can help.
(36:50): And so, it's based on category, so you would go to cancerfinances.org and select the category you need help in. One thing I do suggest, however, is that you think creatively when thinking about financial assistance. Sometimes people will come to me and say, "Well, I need help paying my co-pays, but I can't find help doing that." So, I might suggest, "Well, are there other types of financial assistance, like utility assistance, that you are eligible for?" And then, if you get that utility assistance, you can shift those funds over to help pay for your co-payments.
(37:32): There is support to help pay for prescription drugs. Now, another area where people often struggle is to pay for their prescription drugs. Most pharmaceutical companies and specialty pharmacies have various assistance programs with different eligibility requirements. However, they do more than provide co-pay assistance or free drugs. They often have resources to help with prior authorizations or appeals. Sometimes they can connect you to other types of assistance, like help with transportation or lodging. And so, on cancerfinances.org, we have a tool listing some major pharmaceutical companies and their various programs. You can search this tool by your prescription drug name or company name, and then you'll see what type of assistance is co-payments. Is it free drugs? Is it other types of assistance? And then there's a link specifically to the application process there.
(38:40): Another tool you may have access to is getting lower-cost drugs through a partnership that we have with NeedyMeds, another nonprofit. We have this drug discount card that you can download off our website, and you can take it to your pharmacist and ask, "What would my prescription cost if I were to use this card versus going through my insurance?" And it may be that you get a discount using this card, but really what this card is helpful for is that it starts a conversation between you and the pharmacist, and it lets the pharmacist know that you are concerned about the cost of your prescription drug. And they may even say, "Well, you know what? Your prescription isn't on this discount program, but you can use another discount program." Now, this card has no registration or fee; one card can be used for the whole family, and you can print it out and hand it to your neighbors. There is no sort of registration involved in using this card.
(39:46): Now, in my last couple of minutes, I want to talk about some other programs that aren't really related to your medical bills, but again, it might be helpful if you are struggling financially. So TANF is Temporary Assistance for Needy Families, providing limited cash assistance to eligible individuals. Many times, if you're eligible for one type of program like Medicaid or SSI or SNAP, which is food benefits, you'd be eligible for other types of benefits like TANF, but sometimes you have to ask for those benefits. Suppose you are struggling with food insecurity, which has unfortunately become incredibly common post-pandemic. There are a few different resources in that case, so the USDA National Hunger Hotline can help connect you to local resources.
(40:43): SNAP is the program that used to be referred to as food stamps, but it is the federal nutrition program for women and children; there are different programs. And then, two federally sponsored programs are targeted at helping seniors get high-quality food. There may also be help with your rental or housing costs; as I mentioned, there might be utility assistance. There is a Federal Low Income Home Energy Assistance Program or LIHEAP, and there is an equivalent to help you pay for clean water costs.
(41:24): Some programs also help you access a cell phone or broadband internet. There are two different programs, and I've given you the links here. And so, when I talk about thinking creatively, this is really what I'm talking about. Look at all of these different programs. You might have access to shift funds.
(41:49): But it is not always easy, and it's overwhelming, and every program has different eligibility and applications, and it literally could become a full-time job. I completely understand. We have a checklist for finding financial help that tries to streamline this process for you.
(42:11): Now, I'm going to open it up to see if there are any questions in just a minute, but I do want to let you know that if you're interested in learning more about these topics, whether it's health insurance or employment or disability insurance or estate planning, Triage Cancer has a number of both educational events and free resources on our website. All you must do is register for the events on our website.
(42:38): We also have the opportunity for you to get one-on-one assistance through our legal and financial navigation program. So, anyone is welcome to fill out the form on our website at https://www.TriageCancer.org/GetHelp You'll get an email back with a link to schedule an appointment with us, and then we get on the phone with you, answer your questions, explain your options, and give you the next steps to take.
(43:05): And we often get questions if someone doesn't have a cancer diagnosis but has a different serious medical diagnosis, can they use this program? And the answer is yes, certainly we have the capacity, but we will never turn someone away simply because they don't have a specific cancer diagnosis. So, I just wanted to end with that so that if you have questions that don't get answered today or questions that come up in the future, you know that in addition to BMT and all their phenomenal information, Triage Cancer can also be a resource for you in the future. So, with that, I will turn it back over to see if there are any questions.
Question and Answer Session
(43:44): [Marsha Seligman]: Thank you for this informative presentation. We will now begin the question-and-answer session. The first question is, can you appeal a denial of a claim even though you've already paid the bill instead of appealing it?
(44:16): [Monica Fawzy Bryant]: Potentially, yes, there are timing requirements with respect to appeals. So, you only have 180 days from the claim denial to submit your appeal. But if you're in those 180 days, you could still appeal to the insurance company, and if the insurance company approves your appeal, they would basically pay the provider. The provider would end up refunding you.
(44:45): [Marsha Seligman]: Okay, the next question asks, my employer is trying to terminate me while on long-term disability, and I may lose my health benefits. Is it their right to terminate, and do you have any recommendations on how I should move forward to make sure I get the coverage I need?
(45:04): [Monica Fawzy Bryant]: So that would be a presentation all in itself, but what I say is a couple of things. So long-term disability insurance policies are about payment; they're about money. Because you cannot work due to your disability, no job protection is associated. Usually, someone receives leave through the FMLA, which is job-protected leave, but FMLA leaves only entitle you to 12 weeks of job-protected leave. And so, in many circumstances, after those 12 weeks, barring some other program, if you can't return to work within a reasonable amount of time, then the employer can let you go. I would ask a whole bunch of other questions of you, so that might be something I would refer you to our legal and financial navigation program for.
(46:02): But if you get terminated, and your concern concerns health insurance, you could have several options. If you work for an employer with 20 or more employees, you could have access to COBRA to continue your existing health insurance. You would also have a special enrollment period into the marketplace to purchase a totally new plan because you could also get financial assistance. Based on your income level, you might have access to Medicaid. You might have access to Medicare based on your age and if you're receiving SSDI. As you can see, there are a lot of moving pieces, and we need more information to provide you with your specific next steps.
(46:52): [Marsha Seligman]: Someone would like to know if postage paid for medicine counts against out-of-pocket expenses.
(47:01): [Monica Fawzy Bryant]: Postage paid? Generally, no. If you mean your out-of-pocket maximum, then likely no, because it will be deductibles, co-payments, and co-insurance.
(47:15): [Marsha Seligman]: Okay. I keep hearing about the co-pay accumulator; how would you address this?
(47:22): [Monica Fawzy Bryant]: So, this is an ongoing issue, and I'm going to oversimplify for the sake of time, but essentially what it is when people receive financial assistance from a pharmaceutical company for their prescription drugs. Insurance companies are now saying that they aren't going to count that assistance towards somebody's deductible or out-of-pocket maximum. And so, basically, in the arguments against this, is that insurance companies are essentially double dipping. They're getting paid by the pharmaceutical companies, but then they're not passing that benefit to the patients. It is certainly an advocacy opportunity, so if you are an advocate at heart and want to address this, it is something that you could be talking to your elected officials about because it is very challenging for many patients. Still, as of right now, it is acceptable.
(48:32): [Marsha Seligman]: Someone would like to know what they could do if they cannot afford treatment.
(48:43): [Monica Fawzy Bryant]: It's generally hard to talk about that. I want to know the treatment and why you can’t afford it. Is it because you don't have health insurance, and then we could figure out if you have access to health insurance. If it's an out-of-network provider, could you find an in-network provider that could provide the treatment? If it's a prescription drug, is there a pharmaceutical assistance program? So, what I would say again is that I would need more details to be able to provide useful suggestions effectively.
(49:21): [Marsha Seligman]: I have a lot of bills that are building up; what are the bills I should pay first?
(49:28): [Monica Fawzy Bryant]: So that is a common question, and again, one that can't be answered in the abstract. So if someone is trying to figure out, "Well, what do I pay first and how do I deal with this," I think that is exactly where a consumer credit counseling agency can be helpful because they can look at your exact situation, how much income are you bringing in, what are the sources of income, what are the various sources of bills or debt, and then figure out, "Okay, you need to pay the minimum due here versus a lump sum here," but then it's also about negotiating. So, if someone is getting multiple medical bills, going back to those providers and asking for more time or a payment plan can be very impactful.
(50:18): [Marsha Seligman]: If you get terminated from your job, do your long-term disability also get terminated?
(50:25): [Monica Fawzy Bryant]: If you are talking about a private long-term disability plan, generally, no. The details vary from plan to plan, but the idea behind the long-term disability plan is that they're making up for a percentage of your income that you've now lost because you can't work due to your disability. So, the idea behind them is that they will continue paying even after you no longer have a job. But every policy has different rules, so some long-term policies say, "We're only going to pay you out for a year."
(51:00): Also, remember that if you have a private policy, t many of them will require that you apply for Social Security Disability Insurance or SSDI, and that's the federal long-term disability insurance program; it's very, very common. And what happens is if you get your SSDI, moving forward, your private policy is prorated. So, if you call, let's say, 90% from your private policy and SSDI is going to pay you 50%, you don't get to get more than 100% of what you were making when you were working; it gets prorated. So SSDI pays 50%, and the long-term pays 40%.
(51:47): [Marsha Seligman]: Now that I'm undergoing treatment, can I change my insurance to have a lower out-of-pocket maximum?
(51:54): [Monica Fawzy Bryant]: It depends. So, it depends on where you receive your insurance and what time of year it is. Let's say you have a plan through the marketplace, there is an annual open enrollment period in the fall, and that's when you can make changes for the next calendar year. You could make a change in November. You'd pick a new plan with a lower out-of-pocket maximum, which would kick in on January 1st of next year. Getting diagnosed or needing a bone marrow transplant prevents you from switching plans mid-year.
(52:37): That being said, employers, if you get your insurance through a job, they can pick their open enrollment. So, sometimes they're on a fiscal year or June year. It depends on when their open enrollment is. But outside of open enrollment or another major life change, like moving to a new state or losing your job, you won't have a special enrollment period to change mid-year. But when we talk about medical debt and avoiding medical debt in the future, what you're asking is exactly the suggestion. So even if you don't have a great plan right now and will incur higher medical bills, can you make changes for the next calendar year that minimize those bills moving forward?
(53:30): [Marsha Seligman]: Okay, we are running out of time, so this is going to be our last question, but someone asked about not having insurance and they need a transplant. What do they do?
(53:49): [Monica Fawzy Bryant]: Reach out to us so that I can ask you some more questions, or one of our staff can ask you some more questions so we can figure out what your potential insurance options are, if any because it's going to depend on a lot of factors like what state you live in, and what your income level is, and your household size, and where you're receiving treatment. All of those factors are going to play into what your potential health insurance options are. So please reach out to us.
(54:24): [Marsha Seligman]: Well, on behalf of BMT InfoNet and our partners, I'd like to thank Ms. Bryant for her very helpful remarks, and thank you, the audience, for your excellent questions. Please get in touch with BMT InfoNet if we can help you in any way. Enjoy the rest of the symposium.This article is in these categories: