California Health Insurance

MattsMom

Hi.  I wasn't sure where to put this question, I hope this forum is ok.  I joined the board years ago when I was going through breast cancer.  I'm now 7 years out but have a growth the radiologist says presents as cancer, but needle and MRI guided biopsies say clean.  This second growth appeared on an MRI in April, and my doctor at UCSF wants to keep watching it with MRI's every 6 months. 

My husband changed jobs, and for the first time, (we were Active Duty Military) we are faced with choosing a civilian Health Insurance Plan.  I don't know what to do, what to look for.  His employer offers several.  I want to make sure I can keep getting the necessary, progressive treatment I have been.  Is there an insurance plan in California with a good track record for breast cancer patients?  One to stay away from?  I have heard stories about women losing their insurance because of cancer.  I would appreciate any advice or tips.  Thanks!

07rescue

I wish I knew the health insurance laws in California better than I do. You may need some serious advice on this issue, because it can be very difficult to get health insurance with cancer as a pre-existing condition. I know that you need to maintain what they call "continuous coverage", and not allow any longer than a 62 day break between your last insurance and your new policy in order to have the pre-existing condition covered, otherwise they can restrict your policy to exclude future cancer coverage. I hope you don't run into that kind of trouble.

Are there any California folks here who can better answer this question? I'm on the other coast. 

Celtic_Spirit

I have Kaiser Permanente, Southern California, and have been pleased with my treatment. The doctors and nurses have been great, and I had no trouble getting approved for a prophylactic oophorectomy and zometa infusions as a cancer recurrence preventative. They're also good about covering breast protheses and mastectomy bras. On the downside, they only cover clinical trials they're participating in, and the reconstruction options are limited.

I'm covered through my employer, btw.

loligag

Hi, I've dealt with health insurance during my 20 years of HR experience. When you are in a group plan, the insurance carrier has never, in my experience, cancelled an individual. That usually happens under an individual policy. Hopefully, provisions quoted below under HIPPA law will make it a little clearer regarding pre-existing conditions.

IMHO, if one has a serious health condition, I would stay away from an HMO. Depending on the Primary Care Physician, it could take a long time waiting for referrals. PPO's allow you more freedom and allow you to be more in control of your care. They usually come with a heftier employee contribution and more out-of-pocket expenses. If you are leaning towards an HMO, make sure the PCP's office has their act together, otherwise you'll end up having to fight every step of the way and wait around for referrals. Also, check the list of providers who are contracted with the carrier. In CA my favorites are Blue Cross and Blue Shield. Health Net gets my vote for prescription coverage, which is probably going to be the most expensive part of your treatment. If you go on the carrier websites you can look up all sorts of information before deciding. 

 I'm glad you're being treated at UCSF. They are a comprehensive cancer center and is tops. I am being treated at Stanford. But, if I had to choose again, I would go to UCSF. I still may. If you are looking into integrative medicine, go see Dr. Donald Abrams at the Osher Center for Integrative medicine at UCSF. He's an integrative medicine Oncologist. I found him very helpful as I have Stage IV BC at initial diagnosis. 

 Good luck. PM me if you need more help.

HIPAA permits a group health plan to impose a pre-existing condition exclusion only if a new participant meets one or more of the following conditions:

• Six-month look-back rule. The pre-existing condition exclusion must relate to a condition (whether physical or mental and regardless of the cause of the condition) for which medical advice, diagnosis, care, or treatment was recommended or received within the six- month period ending on the enrollment date;
• Length of pre-existing condition exclusion period. The exclusion period under federal law cannot extend for more than 12 months (18 months for late enrollees) after the enrollment date. However, California law allows no more than a six-month exclusion period after the enrollment date, so you must comply with the shorter six-month exclusion period. HIPAA defines the enrollment date as the first date of coverage or, if there is a waiting period, the first day of the waiting period (typically the date employment begins). The 12- or 18-month “look-forward” period also is based on the anniversary date of the enrollment date; or
• Reduction of pre-existing condition exclusion period by previous coverage. In general, the individual’s days of coverage under a previous medical plan (either individual or group) reduces the pre- existing condition exclusion period.

No pre-existing condition exclusion can be applied in cases involving pregnancy, newborns, or newly adopted children (under the age of 18) who must become covered under the plan within 30 days of birth or the placement for adoption. 2 HIPAA allows Health Maintenance Organizations (HMOs) to substitute a 60-day waiting period (90 days for late enrollees) instead of the pre-existing condition limit.

MattsMom

Thank you for your replies. 

Loligag, I'm a little confused about the exclusion term.  We've had military coverage for the last 12 years, and I'm afraid I don't understand the insurance terms.  For example, my doctor gives the right breast an MRI every 6 months to see if that spot that lights up has changed or grown.  Is that considered treatment, and would it keep me from being covered for my cancer?  Or being covered for an amount of time. 

There should be no lapse in coverage; we will pay COBRA until we can sign up.  Is there any reason Anthem Blue Cross (PPO?) could deny me if the coverage is under my husband's employment?

Thanks!

pitanga

Hi, Matt's Mom! I remember you from way back when. I was stage 2 in those days. not any more, sigh.

I´m sorry you are going hrough this scare but it is very encouraging that your biopsies were clean, especially if it is big enough that they are sure not to miss it when jabbing you. How big is the thing?  My recurrence was only 7 mm but they were able to get it on a stereotactic mammogram-assisted core biopsy.

First time around I was treated in California. I qualified for medicaid but I was told about something called the California Breast Cancer Treatment Fund in case I didnt. They said it was available to all women in the state who didnt qualify for other insurance. I dont know if that has gone by the wayside with all the current budget problems but it is worth checking out.

San Francisco is a fabulous city. Hope you are enjoying it!

Lisa 

loligag

Hi MattsMom,

To be absolutely sure, check the summary plan description of your husband's insurance coverage. I am pretty sure the pre-existing will not affect you. My husband is retired military and we have Tricare Prime (great insurance!) as well as coverage through his current employer.

 I was already dx'd when we joined his new coverage as primary and have had no problems. As far as getting denied coverage through your husband's employer I've never seen it happen on a group plan. A carrier will cancel a group plan for non-payment of premiums or fraud. If the application does not ask any health questions, then it's a large group and it won't matter. If it does, it will matter even less as in CA, small group is more closely regulated than large and cannot be denied.

Once your provider starts submitting claims, Anthem BC will request a Certificate of Group Health Coverage from you to prove continuous prior coverage. My employer has Anthem BC and they have not denied a claim if previous continuous coverage can be proven via the Cert. When they say "treatment" it covers everything, even a dr's visit for a particular ailment.

 Seems to me between the COBRA and your husband's coverage, you are in good shape. Let me know if you need further assistance.

Regards,

Edwina

waniyetu1025

Mattsmom,

 Hello, Well I have Kaiser also, but I also know that Medcal will cover breast cancer and treatments 

CoolBreeze

I'm in Blue Shield's HMO and have been getting good care, through Hill's Physican's Medical Group.  They contract with UCSF.  Somebody else mentioned a PPO instead of an HMO, and that is more convenient as you can self-refer, but you pay more. However, if you have a good primary (as I do) referrals happen in a day or less.  (I'm having troubles with plastics right now but has nothing to do with insurance).  I did have the PPO but was very healthy and decided to save a few bucks - so far that decision hasn't hurt me any.  I've gotten everything necessary and in line with what everybody else gets.

Kaiser in NorCal has Ernie Bodai, a noted breast cancer specialist.  I still wouldn't choose Kaiser for reasons I won't go in to here.  Let's just say I have personal experience about their standard of care with serious disease.  As always with insurance, YMMV and I have heard others who are pleased with them.

I hope it all turns out benign for you. 

JaniceA

Thanks for posting this! Having a health insurance for every member of your family is such a huge help. It can make obtaining quality health care more affordable, it can even pay for all sorts of medical needs, from preventive to treating illnesses. As a parent, it is very important for me to seek medical care for my family to keep them healthy so I obtained a health insurance for them. Hope you'd do it too.