Health+Insurance+Doesn't+Always+Guarantee+Breast+Cancer+Treatment

= Health Insurance Doesn't Always Guarantee Breast Cancer Treatment = by Sandra Gordon Breast cancer is an expensive illness, even if you have health insurance. "With today's treatments, even just the copays on [|prescription drugs] can be as high as tens of thousands of dollars per year," says Marc Hurlbert, the executive director of the Avon Foundation for Women Breast Cancer Crusade in New York City. "The cost of [|medical] care is definitely an issue and not just for uninsured women."

Christina Olachia, a 37-year-old stay-at-home mom of two teens from Katy, Texas, knows firsthand what it's like to pay an insurance premium -- in her case, $590 per month for her family of four -- but not be able to get care. When she was diagnosed in 2006 with triple negative breast cancer, an often extremely aggressive subtype of breast cancer that's likely to recur and metastasize, she had good coverage through her husband's employer insurance plan. Her chemotherapy, modified radical mastectomy and the first phase of breast reconstruction were covered. Then her spouse, Johnny, lost his sales job. Fortunately, he's working again now, but the health insurance coverage his new company offers has a $3,000 per person deductible.

"That's $12,000 our family of four has to pay out of pocket before our insurance kicks in," Christina says. Once they meet their deductible, she and Johnny are responsible for paying 20 to 30 percent of the cost of medical services, which can mount quickly. She's already being hounded by collection agencies for about $15,000 of medical bills she accumulated when she had better health coverage but couldn't handle the out-of-pocket costs. Consequently, "I didn't get my breast reconstruction finished because I can't afford it," Christina says. Her left breast has an implant but isn't fully shaped. It also needs a nipple. Meanwhile, after chemotherapy, Christina developed [|rheumatoid arthritis]. She had a port inserted in her chest and a nurse visiting once a week to administer an immunoglobulin [|drug] that reduces the swelling in her joints and helps her function without pain. But that was when she had good health insurance coverage.

Now her port, which is "bulging" through her chest wall, needs to be flushed to keep blood clots from forming while bottles of immunoglobulin medication sit in her closet. "My neck is stiff most days, and my joints are swollen," she says. She's also overdue to see her oncologist for follow-up care and get a host of necessary tests, including a [|mammogram], an MRI because she has pain in her [|shoulder] -- the side her cancer was on -- and a bone density test. To top it off, Christina has had [|diabetes] since she was a child, which requires insulin and an [|insulin] pump.

"Our health care coverage, including our premiums and our deductibles, adds to about $20,000 per year," Christina says. With an annual income of $50,000, that leaves only about $23,000 for the Olachias to live on after taxes. When you're faced with this level of medical expenses, you have to make some harrowing decisions such as: Am I going to actually spend that $20,000 on medical care, or am I going to skip it so I can make my house payment? Christina has elected to keep a roof over her family's head. "I don't want to acquire any more medical bills because I can't afford them. I basically have no health care. I'm covered, but I can't use it."

It's often easier to get health coverage when you have no insurance and you're low income. But help is out there for the underinsured who lack the income to access the system. What can Olachia -- and the countless other underinsured women like her out there -- do to get the life-saving health care they desperately need? We asked breast cancer advocates and health insurance experts for their top suggestions. Here, their insider's advice for getting affordable help.

Tap into local resources. Breast cancer treatment is fragmented; the amount of free and government-subsidized assistance you can get can varies not only by state, but also by county. To find out about the programs available in your area, start by surfing the Web, making phone calls to local breast cancer organizations, and sending e-mails describing your medical and insurance situation and what you need help with.

At AvonBHOP.org, for example, you'll find Avon-funded breast cancer programs in every state. Similarly, the Avon Breast Health Outreach Program funds 129 outreach and breast cancer screening programs nationwide. To find a funded program in your state, visit AvonBHOP.org/fundingprograms.htm. You can also find information about financial assistance at CancerCare.org. For help with modest out-of-pocket expenses, such childcare or obtaining gas cards so you can get to and from your doctor's appointments, call Avon Cares at CancerCare at 1-800-813-4673.

For financial help with breast reconstruction, visit MyHopeChest.org. This nonprofit organization provides funding for reconstruction surgery to women who have survived breast cancer, but are lacking insurance or the financial means to gain their desired reconstruction. It recruits plastic surgeons around the country who agree to perform the procedure for free or at the Medicaid rate. You'll be placed on a waiting list. For help with co-payments, contact the Co-payment Assistance Foundation at Cancer Care online or at 866-552-6929. "I know hundreds of women have been helped by the copayment assistance foundation," says Hurlbert. Know your health plan. Even if you feel like you don't have good health insurance, learn as much as you can about your coverage. "You're in a better position to navigate the system when you have better information," says Nick Newsad, a senior analyst at a surgery center in Broomfield, Colo., and author of "The Medical Bill Survival Guide."

Go to your health insurance carrier's website and log on to its insurance portal with your health insurance card number. There you'll find your benefit plan, including a list of in-network providers, your deductibles, co-insurance and co-payments. These tools can help you estimate the cost of your treatment. If you're not sure about something, call your health insurance company and ask. Get the name of the person you speak to and the date of your conversation in case there's an issue later. At your health insurance portal, you'll also get access to your explanation of benefits. They're the documents your insurance company sends your provider, telling them what they were paid and what to bill you. "The bill you get from your provider might not match your EOB. If you get billed for more than you should have, you can ask your insurance company to contact your provider about the discrepancy," Newsad says.

Find physicians affiliated with a safety net hospital. A safety net hospital or health system is committed to providing access to care for people with limited or no access to health care due to their financial circumstances, insurance status or health condition. There are more than 100 safety net hospitals in the U.S., including three in Houston, which is 30 miles from Katy, Texas, where the Olachias live.

To find a safety net hospital near you, visit the National Association of Public Hospitals and Health Systems. To qualify for care at a reduced rate or even free at a safety-net hospital, you typically have to make a gross yearly income of less than 200 to 300 percent of the federal poverty level. U.S. Federal poverty guidelines can be found online. For a family of four, for example, 200 to 300 percent of the federal poverty level would be an annual gross income of $44,100 to $66,150. You'd have to make within that range or less to qualify for reduced-rate or free care. (The Olachias qualify.) Another benefit: Safety-net hospitals also have an annual out-of-pocket maximum on health costs, which is typically 25 percent of your adjusted gross income. If your adjusted gross income is $40,000, for example, you'd be responsible for $10,000 of out-of-pocket medical expenses. That's not so great, but with the high costs of breast cancer treatment, it could be worse.

Talk dollars with your doctor and cut your own deals. If you have a high deductible, consider yourself a self-paying patient until that deductible is met. Have a dialogue about money with your doctor before getting services. It might go something like this: "I'm going to have to pay 20 percent of the cost of that procedure, and I can't afford it" or "that's not covered by my insurance."

Talking dollars can be helpful because your doctor might be able to suggest less expensive treatment alternatives. For example, nipple reconstruction can be done under local anesthesia in a plastic surgeon's office for as little as $1,000, compared to as much as $10,000 in a hospital. Can the doctor do it there instead at this reduced rate? Can you go on a payment plan? As a self-payer, don't be afraid to shop around for a doctor who will do what you need done at the lowest price (the provider may need to pre-negotiate the reduced, cash-paying rate with your insurance company). If doctor A agrees to do a certain type of surgery for $2,000 and doctor B will do it for $1,000, you'll save $1,000 by going to doctor B.

For suggested self-pay rates on breast cancer-related and other services, visit HealthcareBlueBook.com. In fact, be prepared to make deals with people all over the place. "You will have to do a lot of homework to fit all the pieces together," says Hurlbert. If the procedure you're haggling over requires anesthesia, for example, be sure to ask the doctor which anesthesiologist she works with and contact that doctor, too, to negotiate a cash-paying price. And don't forget to ask about a facility fee -- and negotiating that, too. Bargain rates are available across the board. Travel to a safety state. Relocating, at least temporarily, may sound far fetched, but consider this: In some states, such as New York, Massachusetts and California, it's just easier to get treatment for breast cancer if you have inadequate or no insurance, says Sandra Blank, herself a breast cancer survivor and the executive director of the Florida Breast Cancer Resource Network in Del Ray Beach, Fla.

But Florida isn't one of those states. It has a county-by-county system, and many counties don't have the federal- or state-funded programs that they should have to pay for treatment and follow-up care for low-income or charity cases, Blank says. It's so bad that she knows women in Florida who've traveled to Massachusetts for breast cancer surgery and didn't even need to show proof of residency.

California, however, is a safe haven. "California's Medi-Cal system, California's Medicaid program, pretty much takes care of everybody, even illegal aliens," says Dr. Suzanne Trott, a plastic surgeon affiliated with Cedars-Sinai Hospital and the Lasky Clinic in Los Angeles. In fact, when hearing about Christina's partially reconstructed breast, Trott considered it unusual. "I've never run across a patient like that because it seems like everybody who wants breast reconstruction [in California] gets it." Source: [|AOL Health]

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