Help navigating USA insurance and employment for a sick relative.
July 31, 2015 10:28 AM Subscribe
One of my relatives has cancer. They’re getting treatment right now and understand the treatment plan. But since we’re in the US, of course there are insurance and employment woes messing it all up. I need help helping them navigate these issues.
There are several specific questions below, but the biggest question is: how does a middle-class family go about navigating health insurance and employment issues without going bankrupt? What kind of resources are we looking for? And what kind of experts do we need to talk to - an employment lawyer? A social worker? Someone else?
The situation: relative is married and they and their spouse are 61 years old. The long-term prognosis is not good, but right now the relative feels reasonably good. We basically don’t know how things will progress past the current round of treatments. What kind of treatment they’ll need in the future and how long they’ll be treated are TBD once they see the outcome of the current treatments. The sick relative and their spouse have enough savings to retire modestly if comfortably, but if they have to start paying for cancer treatments out of pocket this could devastate the savings they have worked so hard to put away. So the goal here is to ensure that the relative gets the treatment they need without leaving themself and their spouse destitute.
At the moment this relative is covered by their employer’s health insurance, which apparently offers very good coverage. They are currently on FMLA while they undergo treatment. But we’re unclear what happens if they can’t work after FMLA, which is very likely - does their employer have carte blanche to fire them?
Regardless, the relative is unlikely to be able to work from now until they’re 65, so insurance coverage until then is an issue. If they are let go from their job then COBRA would be an option but apparently a very expensive option, so they’re worried about relying on COBRA. They could also go on their spouse’s insurance, but it is not as good and their spouse’s job is not especially stable, so they’re not sure that’s ideal. The other possibility we're aware of is to get coverage through their state’s PPACA insurance exchange. The relative was told by a social worker that they are not eligible to get coverage through their state’s PPACA insurance exchange because they are already sick - either no one would cover them or rates would be unreasonable. Based on my understanding, this social worker is criminally wrong - the whole point of the ACA is preexisting conditions are now covered, and the insured should pay the same rates as everyone else. So that’s question 2 - assuming insurance through their employer is no longer an option, can’t they go on the exchange and get coverage at the same rates as everyone else? Relative is not a current smoker.
Making things even more troubling: they just found out that the office that the relative works at is being closed. Some people are being let go and other are moving to another branch. Do they have any rights here to remain employed? Can they be let go in the middle of an illness because their office is being shut down? Do we need to go to an employment lawyer?
Thanks for your help. As I said above, if the answers to these questions depend too much on the specific situation, then answers to “how do we start navigating these questions?” and “what kind of professionals should we be talking to?” would be appreciated.
There are several specific questions below, but the biggest question is: how does a middle-class family go about navigating health insurance and employment issues without going bankrupt? What kind of resources are we looking for? And what kind of experts do we need to talk to - an employment lawyer? A social worker? Someone else?
The situation: relative is married and they and their spouse are 61 years old. The long-term prognosis is not good, but right now the relative feels reasonably good. We basically don’t know how things will progress past the current round of treatments. What kind of treatment they’ll need in the future and how long they’ll be treated are TBD once they see the outcome of the current treatments. The sick relative and their spouse have enough savings to retire modestly if comfortably, but if they have to start paying for cancer treatments out of pocket this could devastate the savings they have worked so hard to put away. So the goal here is to ensure that the relative gets the treatment they need without leaving themself and their spouse destitute.
At the moment this relative is covered by their employer’s health insurance, which apparently offers very good coverage. They are currently on FMLA while they undergo treatment. But we’re unclear what happens if they can’t work after FMLA, which is very likely - does their employer have carte blanche to fire them?
Regardless, the relative is unlikely to be able to work from now until they’re 65, so insurance coverage until then is an issue. If they are let go from their job then COBRA would be an option but apparently a very expensive option, so they’re worried about relying on COBRA. They could also go on their spouse’s insurance, but it is not as good and their spouse’s job is not especially stable, so they’re not sure that’s ideal. The other possibility we're aware of is to get coverage through their state’s PPACA insurance exchange. The relative was told by a social worker that they are not eligible to get coverage through their state’s PPACA insurance exchange because they are already sick - either no one would cover them or rates would be unreasonable. Based on my understanding, this social worker is criminally wrong - the whole point of the ACA is preexisting conditions are now covered, and the insured should pay the same rates as everyone else. So that’s question 2 - assuming insurance through their employer is no longer an option, can’t they go on the exchange and get coverage at the same rates as everyone else? Relative is not a current smoker.
Making things even more troubling: they just found out that the office that the relative works at is being closed. Some people are being let go and other are moving to another branch. Do they have any rights here to remain employed? Can they be let go in the middle of an illness because their office is being shut down? Do we need to go to an employment lawyer?
Thanks for your help. As I said above, if the answers to these questions depend too much on the specific situation, then answers to “how do we start navigating these questions?” and “what kind of professionals should we be talking to?” would be appreciated.
If the person is not capable of working he or she should apply for SSDI (Social Security Disability Insurance). According to this link they will not get Medicare until they've been on SSDI for a while. Its possible that they could be eligible for Medicaid- which is different from Medicare.
i hope they get the coverage they need from ACA.
posted by mareli at 11:16 AM on July 31, 2015 [1 favorite]
i hope they get the coverage they need from ACA.
posted by mareli at 11:16 AM on July 31, 2015 [1 favorite]
Wow, that social worker is totally, criminally wrong. So wrong that I'd be very inclined to report that up the chain at the hospital, because that's very bad information for he or she to continue giving out.
Anybody is eligible to buy insurance on the exchange, at the same rates as others in their geographic area who are the same gender, age, and smoker status. Being able to buy coverage is generally limited to the "open enrollment" period (which runs November 2015 through January 2016), but there are some exceptions, one of which is losing your employer-based coverage. So if your relative does lose their job, they'd qualify to come onto the exchange.
The other piece of that is that while everybody is eligible to buy (full-price) insurance, only people at a certain income level are eligible for federal subsidies towards the cost of premiums. For the purposes of determining eligibility, the government looks at the family income where "family" is defined as the set of people who file a tax return together--in your relative's case, the government would looks at their and their spouse's income. One potential problem you should be aware of is that if your relative's spouse's income is low enough, and your relative loses his/her job, that may put them below the lower limit (100% of the poverty line) to get premium subsidies through the PPACA exchange. What is supposed to occur in that case is the family would move into Medicaid; however, in states that elected to not expand Medicaid, it's possible to fall into a no-mans-land between the two programs and not qualify for any assistance at all. If that happens your relative is still eligible to buy insurance through the exchange, they would just want to be careful when filling out the form to not check the box requesting financial assistance, lest their application be bounced back and forth between Medicaid and the exchange without being able to buy coverage. Or if he/she lives in a state that did expand Medicaid but can afford to and would prefer to remain in private coverage, they would want to make sure they aren't checking that box for financial assistance when they fill out the health insurance application through the exchange, so that they can get passed right through to the stage where they're selecting a plan and making the first premium payment to start coverage.
posted by iminurmefi at 11:19 AM on July 31, 2015 [3 favorites]
Anybody is eligible to buy insurance on the exchange, at the same rates as others in their geographic area who are the same gender, age, and smoker status. Being able to buy coverage is generally limited to the "open enrollment" period (which runs November 2015 through January 2016), but there are some exceptions, one of which is losing your employer-based coverage. So if your relative does lose their job, they'd qualify to come onto the exchange.
The other piece of that is that while everybody is eligible to buy (full-price) insurance, only people at a certain income level are eligible for federal subsidies towards the cost of premiums. For the purposes of determining eligibility, the government looks at the family income where "family" is defined as the set of people who file a tax return together--in your relative's case, the government would looks at their and their spouse's income. One potential problem you should be aware of is that if your relative's spouse's income is low enough, and your relative loses his/her job, that may put them below the lower limit (100% of the poverty line) to get premium subsidies through the PPACA exchange. What is supposed to occur in that case is the family would move into Medicaid; however, in states that elected to not expand Medicaid, it's possible to fall into a no-mans-land between the two programs and not qualify for any assistance at all. If that happens your relative is still eligible to buy insurance through the exchange, they would just want to be careful when filling out the form to not check the box requesting financial assistance, lest their application be bounced back and forth between Medicaid and the exchange without being able to buy coverage. Or if he/she lives in a state that did expand Medicaid but can afford to and would prefer to remain in private coverage, they would want to make sure they aren't checking that box for financial assistance when they fill out the health insurance application through the exchange, so that they can get passed right through to the stage where they're selecting a plan and making the first premium payment to start coverage.
posted by iminurmefi at 11:19 AM on July 31, 2015 [3 favorites]
I'll start at the bottom and work my way up.
“how do we start navigating these questions?” and “what kind of professionals should we be talking to?”
Health Care Navigator :)
Do they have any rights here to remain employed?
Not really. If the plant is closing it is closing. They may, though, get a good severance package that pays for COBRA for some number of months.
Can they be let go in the middle of an illness because their office is being shut down?
Yes, you can be laid off while you are on a protected leave, you just can't be let go BECAUSE you are on protected leave.
Do we need to go to an employment lawyer?
Not at this point. If you think maybe they are being treated differently because they are on leave they can look into an attorney but the outcome will likely be a settlement, not continued employment.
The relative was told by a social worker that they are not eligible to get coverage through their state’s PPACA insurance exchange because they are already sick - either no one would cover them or rates would be unreasonable.
Wrong. The whole point to the exchange is that everyone can get coverage, sick or healthy. Please talk to a navigator. They could also be eligible for subsidies to help pay for it.
does their employer have carte blanche to fire them?
It depends. You only get 12 weeks of federally protected leave, after there there could be ADA disability leaves, etc. but they may have to pay for their health care during that as well. Basically, it depends.
posted by magnetsphere at 11:19 AM on July 31, 2015 [1 favorite]
“how do we start navigating these questions?” and “what kind of professionals should we be talking to?”
Health Care Navigator :)
Do they have any rights here to remain employed?
Not really. If the plant is closing it is closing. They may, though, get a good severance package that pays for COBRA for some number of months.
Can they be let go in the middle of an illness because their office is being shut down?
Yes, you can be laid off while you are on a protected leave, you just can't be let go BECAUSE you are on protected leave.
Do we need to go to an employment lawyer?
Not at this point. If you think maybe they are being treated differently because they are on leave they can look into an attorney but the outcome will likely be a settlement, not continued employment.
The relative was told by a social worker that they are not eligible to get coverage through their state’s PPACA insurance exchange because they are already sick - either no one would cover them or rates would be unreasonable.
Wrong. The whole point to the exchange is that everyone can get coverage, sick or healthy. Please talk to a navigator. They could also be eligible for subsidies to help pay for it.
does their employer have carte blanche to fire them?
It depends. You only get 12 weeks of federally protected leave, after there there could be ADA disability leaves, etc. but they may have to pay for their health care during that as well. Basically, it depends.
posted by magnetsphere at 11:19 AM on July 31, 2015 [1 favorite]
In a similar situation, I discovered that my Sick Friend's insurance has social workers on staff to help with stuff like this. (For free.) They know what the current laws are and had advice about navigating issues like this.
posted by BlahLaLa at 12:20 PM on July 31, 2015
posted by BlahLaLa at 12:20 PM on July 31, 2015
Lots of moving parts in the information you provided!
If your relative's employer is closing, he may be offered severence which often includes a period of paid health insurance. If this is more than just a rumor, HR at his company may be able to offer him information, but if this closure occurs after his 12 weeks of FLMA they would not be obligated to offer him the same benefit. FMLA protects employees only for 12 weeks, and after that the employer can legally terminate employment. Severence isn't legally required, in any case - it's a voluntary offer from an emplolyer so there is no legal requirementit is offered.
COBRA is expensive, because the former employee pays the entire cost of the insurance the employer previously subsidized. It is not possible to pick and choose different levels of COBRA coverage, it's take the entire policy unchanged or leave it, and you pay the entire cost for up to 18 months. As expensive as it might be, the coverage is usually much better than ACA coverage, with lower co-pays and decuctibles. If he is in treatment, taking COBRA insures he can continue with his chosen physicians. Each ACA policy will have its own network, and finding a policy that includes his doctors might be tough. The drugs covered by his employer policy might be different from an ACA policy, as well. Keep in mind that if he switches policies this year, his copays and deductibles will start over - decuctibles paid to one insurer do not count if a new insurer comes into the picture. This can cost thousands, and can make COBRA look like a good deal, at least until the end of 2015.
Looking into going on his spouse's policy might be a reasonable move. At the very least, I suggest your relative carefully compare his spouse's policy against specific ACA policies to see if the same doctors and medications are covered, and how the copays and decuctibles compare. This is no easy task. You need to approach this like you are an accountant who crunches numbers before breakfast. For ACA information your relative's State of residence is essential, since policies are offered within each state, and a policy offered in California, for example, will not be offered in Wyoming or Texas. Minimum covered conditions and levels of coverage (silver, bronze, etc.) are standard and mandated by the ACA, but not the networks of physicians and hospitals or drug formularies.
If your relative decides that he will be permanently unable to work and chooses to pursue Social Security Disability be advised that if awarded it requires a 2 year wait before Medicare kicks in. Medicaid does not have this requirement but you will probably find that the income requirements to qualify for Medicaid are draconian. Spend-down of assets is typically required in order to become elegible.
I'm deeply sorry this mess is the best we can do in our country, but our seeming religion of protecting profit prevents us from instituting the obvious solution, which would eliminate most of the issues above. We need single payer healthcare in America! I wish the best for your relative.
posted by citygirl at 8:30 PM on July 31, 2015
If your relative's employer is closing, he may be offered severence which often includes a period of paid health insurance. If this is more than just a rumor, HR at his company may be able to offer him information, but if this closure occurs after his 12 weeks of FLMA they would not be obligated to offer him the same benefit. FMLA protects employees only for 12 weeks, and after that the employer can legally terminate employment. Severence isn't legally required, in any case - it's a voluntary offer from an emplolyer so there is no legal requirementit is offered.
COBRA is expensive, because the former employee pays the entire cost of the insurance the employer previously subsidized. It is not possible to pick and choose different levels of COBRA coverage, it's take the entire policy unchanged or leave it, and you pay the entire cost for up to 18 months. As expensive as it might be, the coverage is usually much better than ACA coverage, with lower co-pays and decuctibles. If he is in treatment, taking COBRA insures he can continue with his chosen physicians. Each ACA policy will have its own network, and finding a policy that includes his doctors might be tough. The drugs covered by his employer policy might be different from an ACA policy, as well. Keep in mind that if he switches policies this year, his copays and deductibles will start over - decuctibles paid to one insurer do not count if a new insurer comes into the picture. This can cost thousands, and can make COBRA look like a good deal, at least until the end of 2015.
Looking into going on his spouse's policy might be a reasonable move. At the very least, I suggest your relative carefully compare his spouse's policy against specific ACA policies to see if the same doctors and medications are covered, and how the copays and decuctibles compare. This is no easy task. You need to approach this like you are an accountant who crunches numbers before breakfast. For ACA information your relative's State of residence is essential, since policies are offered within each state, and a policy offered in California, for example, will not be offered in Wyoming or Texas. Minimum covered conditions and levels of coverage (silver, bronze, etc.) are standard and mandated by the ACA, but not the networks of physicians and hospitals or drug formularies.
If your relative decides that he will be permanently unable to work and chooses to pursue Social Security Disability be advised that if awarded it requires a 2 year wait before Medicare kicks in. Medicaid does not have this requirement but you will probably find that the income requirements to qualify for Medicaid are draconian. Spend-down of assets is typically required in order to become elegible.
I'm deeply sorry this mess is the best we can do in our country, but our seeming religion of protecting profit prevents us from instituting the obvious solution, which would eliminate most of the issues above. We need single payer healthcare in America! I wish the best for your relative.
posted by citygirl at 8:30 PM on July 31, 2015
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posted by goggie at 11:02 AM on July 31, 2015 [1 favorite]