Navigating the myriad cancer-related legal issues confronting a patient after a cancer diagnosis can be enormously challenging, particularly when that person is in the throes of treatment. According to attorneys Joanna Fawzy Morales, CEO, and Monica Bryant, COO, of Triage Cancer, a clearinghouse for patients and caregivers covering practically every potential issue related to a patient’s legal rights, a general understanding and knowledge of where to seek answers should enable them to better navigate these difficult issues and relieve some of the burden on themselves and their families.
At the Academy of Oncology Nurse & Patient Navigators 11th Annual Navigation & Survivorship Conference, Ms Morales and Ms Bryant introduced participants to the impressive array of resources that Triage Cancer has marshaled, covering the spectrum of relevant legal issues applicable to patients with cancer and professionals in the medical field. Triage Cancer provides webinars, training conferences, quick guides and checklists, animated videos, and charts specific to each state’s laws.
Key Topics: Medical Insurance
When the Affordable Care Act (ACA) was adopted by Congress in 2010, Americans were required to have health insurance, or pay a penalty for not having it.
“But in 2017, Congress passed a budget resolution lowering the penalty to $0. This is pretty significant, because beginning in 2019, the penalty was $0 if you didn’t have health insurance,” Ms Morales noted. “But then a handful of states promptly passed state laws stating that there was still an insurance requirement in those states, and that the penalty was similar to what it was at the federal level.”
The 3 potential sources of coverage are private insurance companies, government programs (Medicare, Medicaid, military benefits, etc), and employer-provided insurance, which is the largest single source at present.
The presenters pointed out a number of provisions of the ACA that have been particularly impactful since its adoption, the most important being the ban on denials of coverage for people with preexisting conditions (physical or mental), or on the basis of gender or age. It also includes protections relative to premiums, which deals with individual versus family coverage, geographic location, and caps on increases due to age and tobacco usage. For lower-income families, the expansion of Medicaid coverage has been crucial; the addition of adults with household income under 138% of the federal poverty level to Medicaid eligibility has resulted in a significant increase in the number of people able to obtain health coverage in the United States.
The ACA established state health insurance marketplaces, referred to as “exchanges,” for the purchase of insurance, but approximately 67% of people who would be eligible for coverage through the exchanges have not utilized this resource.
The ACA is currently pending before the United States Supreme Court in the case of California v. Texas, which essentially puts the constitutionality of the ACA on trial. Should the act be found unconstitutional, the above protections will be eliminated, and Congress will have to consider new legislation to protect the rights of patients with cancer.
“If the Supreme Court does strike down the ACA, all of the consumer protections we mentioned, as well as many other things touching every aspect of our healthcare system, will change or go away entirely,” said Ms Morales. “So we want people to be aware of this case.” More in-depth information on the status of the case can be found at the Triage Cancer website (triagecancer.org).
According to Ms Morales and Ms Bryant, patients should be familiar with their insurance coverage, and particularly with the type and extent of that coverage as it pertains to their condition. Basic understanding of such terms as the premium cost, the size of the annual deductible, any copayments required at point of service, coinsurance/cost-sharing obligations, and out-of-pocket maximums all bear on the overall cost of treatments. Maybe not surprising is that only 23% of people surveyed by Triage Cancer understood the terms used in their policy, and only 50% knew the amount of their monthly premium. A patient should also be aware of state and federal consumer protections and benefits as they relate to coverage, as well as existing appeal rights in the event of denial of coverage. Triage Cancer provides excellent resources related to appeals of denials of both employer- sponsored and individual health insurance, information on accessing medical records for the appeal, and useful tracking forms.
Employment Rights and Responsibilities
The Americans with Disabilities Act and the Family and Medical Leave Act (FMLA) are federal laws that apply to every state. But Ms Morales noted that employment laws are only a baseline, and many employers can and do provide more benefits to employees than is required by law.
First of all, patients should know what protections are provided by these laws and should also know what, if any, state law protections are applicable. Employees need to become well versed in the employer-provided handbook regarding issues such as leave policies, procedures for applying for FMLA, medical leave policies, and the reasonable accommodation process. The FMLA provides 12 weeks of unpaid job- and health benefit–protected leave for one’s own serious health condition or to take care of a parent, spouse, or child. Ms Bryant emphasized that this protected leave is unpaid, but noted that it may also apply to some part-time employees.
“Financial Toxicity” is a term that describes an enduring problem in the medical field; the effect of out-of-pocket expenses on the cancer treatment experience. According to the authors of a 2013 study out of Duke University, who conducted a study on financial toxicity, “Out-of-pocket expenses related to treatment are akin to physical toxicity, in that costs can diminish quality of life and impede delivery of the highest quality care.”
The primary antidote is adequate health insurance that minimizes total out-of-pocket costs, but a number of other factors can contribute to this toxicity, such as change or loss of employment, moving, divorce, inability to work, and graduation. Triage Cancer’s website provides guides to help patients avoid this toxicity trap.
Of particular interest to seniors is information provided by Triage Cancer regarding Medicare options. There is what is referred to as “original” Medicare, and there are Medicare Advantage plans; Medicare Part A provides inpatient/hospital coverage, and Part B covers outpatient/medical care (Part B only covers 80% of the cost, but the 20% gap can be covered through private company policies). Also available are Part D prescription drug plans, either through Medicare or private insurance.
Medicare Advantage plans are provided by private insurance companies under contract to Medicare and provide similar coverage under preferred provider organization and health maintenance organization (HMO) plans. Some limitations such as choice of doctors and hospitals do exist under the Medicare Advantage HMO option, so patients should inform their choices of coverage accordingly. Each year between October 15 and December 7, people have the opportunity to review their coverage and, if needed, move from original Medicare to a Medicare Advantage plan, or to make changes to their coverage within the existing plan. According to Ms Morales and Ms Bryant, this is particularly important to patients with cancer, since coverage needs can fluctuate over the years.
“The good news is, as of right now, we have the opportunity to make changes every single year, and to be savvy consumers,” said Ms Bryant. “We need to make sure we’re reviewing our options every single year, and picking something that will meet our upcoming needs.”