Insurance

After the emotional and physical impact of a breast cancer diagnosis, dealing with insurance can be overwhelming. The information in this section may help you understand insurance.

Step 1: Understand the basic types of insurance

The types of insurance most important for people with breast cancer are:

  • Health insurance pays for some or most of your medical care costs. You may have insurance through your employer or the government (such as Medicare). Or, you may have a plan you bought yourself.
  • Disability insurance provides part of your income if you can’t keep working during or after breast cancer treatment. It can be short-term or long-term.
  • Long-term care insurance covers any help needed if you become unable to care for yourself. You may get this care in your own home or in a nursing home.

A health insurance policy is a legal agreement where an insurer gives coverage for some or most of your medical care costs for a certain price.

Learn more about health insurance including how to compare plans, how to maintain coverage if you lose your job, what to do if a claim is denied and more.  

What is disability insurance?

Disability insurance pays part of your income if you become too sick to work (any job, not just your current one). Most policies pay about 60 percent of your salary.

Disability can be short-term or long-term, depending on the length of time you are unable to work. Short-term disability is usually less than 6 months.

How to get disability insurance

Private insurance companies offer short-term and long-term disability insurance plans. Some employers provide disability insurance. If you’re employed, check the details of the coverage.

You can also buy disability insurance on your own or add to the coverage your employer provides.

Some people can get long-term disability benefits from the Social Security Administration. Learn more about these benefits below.

Buying or choosing disability insurance

If you are buying or choosing disability insurance, check the following:

  • How the term “disability” is defined
  • The extent of disability (partial or total) before payments begin
  • Whether you can renew the policy
  • Residual benefits (partial payments if you are still able to work, but in a more limited way that causes a decrease in income)
  • Size of monthly benefits
  • When payments begin (between 1-6 months after the disability)
  • Length of coverage 
  • Cost-of-living adjustments to keep pace with inflation

Social Security Administration disability benefits

The Social Security Administration provides monthly payments to people of all ages who:

  • Are unable to work for at least 12 months due to a disability
  • Have a terminal illness 

People with breast cancer (especially those with stage IIIB or stage IIIC breast cancer, or metastatic breast cancer) may qualify for two types of benefits:

  • Social Security Disability Insurance (SSDI)
  • Supplemental Security Income (SSI)

Medical eligibility is the same for SSDI and SSI, but each program has its own non-medical criteria.

Social Security Disability Insurance

Social Security Disability Insurance (SSDI) benefits are available for people ages 18-65 who have worked throughout their lives.

SSDI is funded by payroll taxes. You are eligible as long as you have:

  • Worked for any 5 of the past 10 years (less if you are young) and 
  • Earned a certain amount of taxable income in those years (for example, in 2020, you must have earned at least $5,640 per working year).

SSDI payments depend on your salary and years of work, but most people get about $1,100 per month. You can get an estimate of payments from your local Social Security Administration office. To find an office near you, visit the Social Security Administration’s website.

Learn more about SSDI.

SSDI and Medicare

Once you get SSDI payments, you are eligible for Medicare 24 months after your breast cancer became “disabling.” This isn’t necessarily when you applied for disability benefits, but when your breast cancer kept you from earning income.

If you want to get Medicare, apply as soon as you can. Enrollment can take some time and there’s no way to speed up the process.

SSDI benefits for your family

If you get SSDI payments, your family may also be eligible for some benefits.

The following family members are eligible for up to 50 percent of your monthly SSDI payments. (These payments are in addition to what you get.)

  • Children ages 18 and younger 
  • A spouse over age 62
  • A spouse sharing in the care of your children under age 16

Your household payment limit is about 180 percent of your currently monthly payment. For example, if your SSDI payment is $1,000 per month, then your household payment limit is $1,000 x 1.8 = $1,800 per month.

Supplemental Security Income

Supplemental Security Income (SSI) benefits have no work requirements and are available for people of all ages. SSI can be a good option for those who haven’t worked recently, such as a parent who took time off work to raise a family.

However, SSI benefits are for those with the most need, so there are strict income and resource limits. You aren’t eligible for SSI if:

  • Your taxable income is more than $783 per month in 2020 
  • You and your spouse’s combined taxable income is more than $1,175 per month in 2020
  • Your spouse’s income is above the federal poverty level 
  • You have any large “resources” (including more than $3,000 cash in savings, a second home, a second car, stocks, bonds or life insurance)

If you’re eligible for SSI, you can automatically be enrolled in Medicaid in most states.

Unlike SSDI, there are no SSI benefits for family members.

Learn more about SSI.

Learn more about resource limits for SSI.

Applying for Social Security Disability Insurance or Supplementary Security Income benefits

You can apply for Social Security Disability Insurance (SSDI) online.

With Supplementary Security Income (SSI), part of the application can be done online. However, you will need to go to your local Social Security Administration office to complete the process. To schedule an appointment, call the Social Security Administration toll-free at 1-800-772-1213. (Be sure to make an appointment. If you just show up, there may not be anyone to help you.)

For both applications, the Social Security Administration will need to confirm your breast cancer diagnosis. You don’t need to submit any medical records. However, you’ll need to list the hospitals where you’ve had treatments, as well as the doctors who’ve treated your cancer so the Social Security Administration can contact them.

On your application, give as much detail as you can about your surgery and other treatments (such as radiation therapy, chemotherapy and other medications) and general well-being. This can help your chances of approval.

Apply for SSDI or SSI benefits online.

Find your local Social Security Administration office.

If you have questions about SSDI or SSI, email the Social Security Administration at help@disability-benefits-help.org or call them toll-free at 1-800-772-1213.

Long-term care insurance can cover any help needed if you become unable to care for yourself. You may get this care in your own home or in a nursing home.

Long-term care insurance may cover a wide range of services beyond medical care, including:

  • Visiting nurses
  • Meal delivery
  • Help with chores
  • Help for caregivers

Long-term care can be expensive.

Most long-term care policies pay a fixed amount for each day you get care (ranging from $50 to hundreds of dollars per day). Daily benefits for at-home care are at the lower end of the range, while nursing home care is the most expensive.

Buying long-term care insurance

If you are buying a long-term care policy, consider the following:

  • Which services are covered (such as nursing home care, home health care, adult daycare and help for caregivers)
  • Daily payments for each service
  • How long the benefits last
  • Maximum lifetime benefit (if any)
  • Maximum length of coverage for each period of confinement (at home or in a nursing home)
  • The period of confinement before premiums are waived
  • Waiting period for pre-existing conditions
  • What assessments or exams are needed
  • Whether you can renew the policy
  • Age range for enrollment
  • Whether there’s a waiver-of-premium (This states the insurer will keep up your policy without premiums if you become totally disabled before age 60 or 65.)
  • Whether the policy has a nonforfeiture benefit (This protects a portion of your benefits if you stop paying premiums.)
  • Whether the policy has an inflation adjustment feature (This increases your benefits by a small percentage each year. The increase helps ensure coverage bought today will pay for the cost of long-term care in the future.)
  • Cost of the policy 

No insurance plan covers all the costs related to breast cancer care. However, some cover more than others.

In order to plan ahead, it’s important to find out how much of your medical treatment costs you will need to pay. Also, find out what other out-of-pocket costs you’ll have to pay.

  • Is there a difference in coverage for doctors and/or treatments considered “in-network” versus “out-of-network?” 
  • Which costs are covered (office visits, blood tests, surgery, chemotherapy, etc.)? How much of each is covered? Are there co-pays (co-payments) or deductibles?
  • What is the process for reimbursement?
  • What is my prescription drug coverage? How much is my co-pay? Is there a cap for this coverage? Is it likely my drug costs will reach that cap (if you already know the drugs you will be taking)? What happens after I reach the cap?
  • When I need to stay overnight in the hospital for treatment, what costs are covered? What costs are not covered?
  • Are second opinions covered? How do I go about getting a second opinion?
  • Are any complementary and integrative therapies (such as acupuncture) covered?
  • If I join a clinical trial, what costs are covered?

Step 2: Review your current insurance plans

The next step is to review your current plans to see what coverage you have for each type of insurance.

If you work, start by reviewing the coverage given by your employer. It’s a good idea to meet with someone from the human resources department to go over your questions.

If you don’t work, you may want to talk about your insurance options with a hospital social worker or someone in the hospital financial information office. You can also contact your state or local health department.

When reviewing your insurance plans, be sure to read the policies themselves and not just the marketing brochures that describe them. An insurance policy is a legal contract that describes your rights and responsibilities, as well as those of the insurer. It deserves the same level of attention as any other legal document.

Step 3: Talk to a financial counselor at your hospital or medical center

Most hospitals and treatment centers have financial counselors. They can help you with the details of your insurance paperwork and give you an estimate of the cost of your treatment.

Financial counselors can also help you work out a payment plan for the costs you’ll have to cover. If you’re not able to pay, some places may reduce or wave the costs if you ask.

No matter your income, you may qualify for financial aid from federal or state programs. A financial counselor can help you learn about these programs.

Things to keep in mind when working with insurance providers

When buying insurance:

  • Work with an insurance agent or agency that’s licensed by your state insurance department.
  • Never cancel an old policy until a new one is in effect.
  • Make sure you know the limits of your new policy.
  • Check the application to make sure the information is correct. False or incorrect information may cause denial of some benefits or even cancellation of a policy. 

When dealing with an insurance company or agent:

  • Understand and follow the policies and procedures as best you can.
  • Ask questions about any unclear policies and procedures.

Make a folder for each insurance policy:

  • Keep copies of the policies, claim forms, invoices and letters.

Keep a log of phone calls, including:

  • The date and time of the call
  • The person you spoke to (name and job title)
  • A brief summary of the call
  • Any actions that were to result from the call

SUSAN G. KOMEN® SUPPORT RESOURCES

  • If you or a loved one needs more information about breast health or breast cancer, call the Komen Breast Care Helpline at 1-877 GO KOMEN (1-877-465-6636). All calls are answered by a trained specialist or oncology social worker in English and Spanish, Monday through Friday from 9:00 a.m. to 10:00 p.m. ET. You can also email the breast care helpline at helpline@komen.org.
  • Komen Affiliates offer breast health education and some fund breast cancer programs through local community organizations. Your local Affiliate can also help you find financial assistance programs and other resources in your area. Find your local Affiliate.
  • Our fact sheets, booklets and other education materials offer additional information.

 

TOOLS & RESOURCES

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