For introductory information and to understand the mission of this blog, please see Post 1
Health Insurance Marketplace: Part 4
Essential Health Benefits
Welcome back! I hope this blog is providing helpful information for people living with cancer. In this post, I want to continue our discussion into the Health Insurance Marketplace (Marketplace), focusing on the Essential Health Benefits (EHB) as they relate to people living with cancer.
You can find more information on the Marketplace at www.healthcare.gov or calling 1-800-318-2596. They even have a blog at www.healthcare.gov/blog
If you live in California, Colorado, Connecticut, District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, Nevada, New York, Rhode Island, Vermont, or Washington, use this link to find your state’s website for health insurance https://www.healthcare.gov/marketplace-in-your-state/#:~:text=People%20in%20most%20states%20use,business%20health%20coverage%2C%20or%20both.
What are Essential Health Benefits (EHB)?
Depending on where you live, health care coverage varies with the type of Marketplace plan that you choose. According to www.CMS.gov, The Affordable Care Act, which sets the standards for the Marketplace, requires “non-grandfathered health plans in the individual and small group markets to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services”. The exact coverage details and cost-sharing amounts for individual services will vary by plan, and some plans may require prior authorization before these services are covered. Look for the Summary of Benefits and Coverage (SBC) on each plan’s page for more details.
What does this mean?
In general, most health insurance plans available on the Marketplace, will cover a portion of the bill for services provided in any of the 10 EHB benefit categories above (once you reach your deductible- see “Insurance Vocabulary” post). You will be responsible to pay the portion of the bill that the plan does not cover, until you reach the plan’s “out of pocket maximum.” Keep in mind this will be in addition to your monthly premium payments. You want to look for a plan that you can afford the monthly premium, deductible, and co-pays.
What cancer care services are included in these categories?
- Ambulatory Patient Services: Healthcare services that you can receive without being admitted to the hospital. Typically, this includes visits to your doctor’s office, clinic, same day surgery center and outpatient hospital departments. Services include administration of chemotherapy (if given in your doctor’s office), less expensive x-rays and radiation treatments. There are a variety of types of radiation treatments. Confirm with your health care team that the insurance plan will pay for the type of radiation you need prior to purchasing the plan. Pre-authorizations are often required before the insurance plan will pay for these services.
- Emergency Services: In an emergency, you should receive care at the closest hospital to you. Typically, emergency services include health care that is required to “stabilize” your health. Some, but not all plans count Urgent Care as emergency services.
It is my experience that people living with cancer will procrastinate going to the emergency room until their symptoms are life threatening. Many are afraid that they will be unable to continue cancer treatment if they admit that they are having side effects. This is often not true. All cancer treatment teams have providers on-call 24 hours a day/ 7 days a week. Call them!! Physician ordered emergency department visits are covered by most insurance plans.
If you are going the emergency room, take your cancer organizer/binder. The closest hospital to you may not have access to your cancer treatment medical records. This will save time coordinating your care.
- Hospitalization: Healthcare services provided inside the hospital, often requiring an admission and an overnight stay. This includes surgeries, medications, and nursing care. Chemotherapy that requires a hospital admission is also included. If you have an advanced cancer diagnosis requiring surgery, chemotherapy, and radiation, you may want to plan for at least one hospitalization during your cancer treatment. Marketplace plans vary in payment for services received during hospitalizations. Once you have reached your “out of pocket maximum”, the plan will continue to cover your care.
- Mental Health: Services to evaluate, diagnose and treat a mental health condition or substance abuse disorder. These services can be provided as an inpatient or outpatient. There are a few challenges with insurance coverage for mental health services. If you would benefit from counseling to cope with a new cancer diagnosis, but have not been diagnosed mental health condition, your plan may not pay for the counseling services. If you have a diagnosed mental health condition, but have not been in active mental health treatment, you may experience a wait time for a new patient consultation with an “in network” mental health provider.
This is where your cancer treatment team can step in. Often treatment centers offer cancer support services which include social workers and mental health services at low or no cost to you. Every person living with cancer should be offered mental health support services. Talk with your doctor to determine which is the best choice for you.
- Prescription Drugs: Medications that require a prescription from your healthcare team, including chemotherapy. Each health insurance plan has a list of medicines that they will pay for called a formulary. This becomes confusing, as many plans have “tiers” for payment of different medications. Lower tiered medications are less expensive. Higher tiered medications are more expensive. Plans may limit the quantity of medications that will be paid for. Pre-authorization may also be required. Treatment with chemotherapy rarely includes only one medication. Talk with your cancer treatment team and review the formulary before deciding on a plan.
- Rehabilitative Services and Devices: Services that help a person keep, resume, or improve activities for daily living (walking, bathing, feeding yourself, etc.) that have been lost or impaired because a person was sick. These services may include physical, occupational and speech therapy. The services can be received as an inpatient or outpatient. Plans vary on the amount of therapy covered as well as co-pays for services.
- Laboratory Services: In addition to blood, urine, and other body fluid tests, expensive imaging testing (MRI’s, CT scans) may also be included in this category. Biopsies (tissue samples) and pathology (nasal & throat cultures, etc.) are also included. Each plan has “in-network” and “out of network” laboratories that they contract with. Services received from “in-network” labs will result in less out of pocket cost to you. If you are having blood work or a biopsy at your doctor’s office, request that the specimen goes to an “in-network” provider. This is a common request, so don’t feel embarrassed to bring it up.
- Preventative & Wellness Service/Chronic Disease Management: Health care services that include colon, lung, breast, and cervical cancer screenings as well as tobacco cessation interventions, flu & pneumonia vaccines. Genetic testing for breast cancer patients is included. These services are free if they are provided by a provider in your plan’s network.
I hope this information is helpful. If you would like to continue this conversation, please click on the Subscribe button at the top of the Blog page. I would love to hear your comments as well as resources that have worked for you. Please share this information with your family and friends.
Keeping you in my prayers,
Jackie