What happens if you get cancer and do not have health insurance? Most patients can still get treatment but can run out of money in a hurry.
Fortunately, the United States provides residents with a safety net. Nobody has to go uninsured for more than 12 months, and many people can get coverage in far less time.
Having a third party pay for surgery, chemotherapy, and radiation beats reaching into your wallet. Learning the applicable laws can help you get medical services in the interim, find financial help, and perhaps shorten the time that you have to self-pay to fight this dread disease.
Getting Cancer Treatment without Insurance
Learning the pertinent laws and using them to your advantage is the key to getting cancer treatment without insurance. There are four critical rules to know, which we will show you how to exploit to your advantage is this section and the next.
- IRS Section 501(c) (3) rules require non-profit hospitals and medical centers to meet several standards[I]
- Provide emergency services regardless of the person’s ability to pay
- Offer non-emergency services to people with the ability to pay by themselves
- Provide free or subsidized care to the indigent
- Medicaid rules create three pathways for coverage
- Social Security Disability recipients
- Breast and Cervical cancer patients
- Medically needy people who spend down income
- The Affordable Care Act has three key provisions
- Cover pre-existing health conditions without waiting periods
- Begin after an enrollment period (annual or special)
- Provide income-based subsidies
- Patients turning age 65 can sign up for Medicare
Uninsured patients with sufficient income can get non-emergency cancer treatments by paying out of their own pockets. Under IRS rules, non-profit providers cannot deny care if you have the resources to pay by yourself.
Of course, the self-pay options are costly. Fortunately, legal residents of the U.S. only have to bear these high costs for a maximum of twelve months, and often the timing is much shorter. See the next section for timing issues surrounding the start dates for coverage.
Meanwhile, the extremely high cost of care can accelerate eligibility for Medicaid under the “Medically Needy” category supported in many states. This provision allows cancer patients to spend down their income on treatments until they meet earnings requirements. The average annual costs standard procedures can provide a benchmark against your household earnings.
- Surgery (double mastectomy: $10,000
- Hospitalization (5 days): $10,000
- Chemotherapy: $100,000
- Radiation: $10,000
Uninsured patients with meager incomes (indigent) can get cancer treatments by applying for financial help at a non-profit hospital or medical center.
Under IRS rules, non-profit providers must have a written financial assistance policy that meets minimum standards.
- Applies to all emergency and other medically necessary care
- Is widely publicized
- Includes eligibility criteria for financial assistance
Other state government programs offer monetary support in smaller bits. Be sure to take advantage of medical tax deductions, short-term disability, unemployment compensation, and family leave laws where applicable.
The Cancer Financial Assistance Coalition (CFAC) does not respond to individual requests for help. However, it does publish a directory that can narrow down your search for resources based on your diagnosis, zip code, and type of support needed (lodging, supplies, meals, etc.).
(CFAC) consists of 14 member organizations that joined forces to help patients experience better health and well-being by limiting monetary challenges.
- American Cancer Society
- Be The Match
- Cancer Support Community (CSC)
- Good Days
- The HealthWell Foundation
- The Leukemia & Lymphoma Society
- Lymphoma Research Foundation
- The Max Foundation
- National Organization for Rare Diseases (NORD)
- The Patient Access Network (PAN) Foundation
- Patient Services Incorporated
- Sarcoma Alliance
Getting Health Insurance When you Have Cancer
The Affordable Care Act (ACA) guarantees your ability to get health insurance when you have cancer. The ACA requires that new enrollees receive coverage for any pre-existing health condition with no waiting periods.
However, the ACA does not assure that uninsured patients can begin a new policy anytime they encounter a severe medical problem. Patients may have to delay the start date to coincide with an enrollment period – unless they qualify for free government-sponsored coverage under Medicaid or Medicare.
In other words, this is a question of when, during any calendar year, the new policy begins, rather than if you can get coverage for your treatments.
Cancer patients can get private health insurance that covers most treatments but only during an open enrollment period. The coverage would begin in the month after the close of this designated sign-up time frame.
- Employers can pick any time of the year to schedule the open enrollment date for their private group healthcare plans. You may get lucky if your (or your spouse’s) workplace coverage begins at a convenient time.
- Individuals can buy private health insurance only during the annual open enrollment that begins on November 1 and ends on December 15. Coverage begins on January 1st of the New Year.
- People who experience a Qualifying Life Event can begin private health insurance within 60 days of an eligible change[II].
- Household Changes
- Got married
- Had a baby, adopted a child, placed a child in foster care
- Lost insurance
- Changes in Residence
- Proof of coverage during the last 60 days
- No evidence if moving from a foreign country
- Loss of health insurance
- Job-based coverage
- No longer meet eligibility criteria
- Individual plans
- Medicaid or CHIP
- Via family member
- Other Reasons
- Recognized as a tribal member
- Become US citizen
- Leaving incarceration
- Household Changes
The federal government supports two possible forms of free or very low-cost health insurance (Medicaid & Medicare) for cancer patients. You could qualify for no-cost coverage if you meet the financial criteria and fall into a protected class as stipulated by your state.
Plus, the timing often works much better because you may not have to wait for an annual open enrollment period. You could start right away once you meet the qualifications.
Medicaid is the first place to turn for cancer patients without insurance. You might be eligible for free coverage depending on your household income, and the state where you live. Also, you could enjoy two critical advantages.
- Newly eligible people can begin coverage during the application month with no waiting for open enrollment
- Process claim payments three months retroactively for any tests, lab work, and other services if qualified during this time
Many cancer patients can easily enroll in Medicaid any time during the year if they live in one of the 36 expansion states. The Affordable Care Act allows states to expand eligibility criteria to include low-income families (below 138% of the federal poverty level – $17,236 for an individual in 2020) who do not fit other narrowly defined groups (see below).
Providing the income documentation that reflects your current earning status is the key to success. Many people suffer a sharp drop in income shortly after diagnosis because the treatments are often debilitating. Therefore, provide the agency with copies of your most recent (lower) paystubs, rather than last year’s (higher) tax returns from when you were able to work full-time.
Only narrowly-defined groups of people in protected classes can enroll in Medicaid if they live in a non-expansion state. Plus, the household income limits are often far below the federal poverty level. You may need to fit into one of these groups to qualify.
- Over the age of 64
- Pregnant or have a child 18 or under
- Blind or disabled*
- Have specific types of cancer**
- Have a child, parent, or spouse in your household who is blind or disabled
- In a skilled nursing or intermediate care home
It may be harder to meet the eligibility rules if you live in one of fourteen non-expansion states[III].
|North Carolina||Oklahoma||South Carolina|
The same holds if you live in a state that has adopted but not yet implemented the expansion changes (as of November 2019)
Uninsured cancer patients can qualify for Medicaid if they meet the Social Security definition for disability under either of the two programs[IV]. However, be aware that the approval takes a long time, and SSDI has a five-month waiting period.
- Supplemental Security Income (SSI) for people with disabilities since birth and senior citizens over age 65
- Social Security Disability Income (SSDI) for adults who have disabling conditions acquired through illness, injury, or trauma
Social Security publishes a detailed listing of medical criteria that apply to the evaluation of impairments in adults. You can find the requirements for Malignant Neoplastic Diseases here.
SSDI recipients become eligible for Medicare after a 24 month waiting period.
Breast & Cervical**
All fifty states provide Medicaid coverage to women diagnosed with breast or cervical cancer through the Centers for Disease Control and Prevention (CDC) Early Detection Program (NBCCEDP).[V]
The CDC offers free screenings to women who meet these standards.
- Uninsured or insurance does not cover exams
- Yearly income is below 250% of the federal poverty level
- Between 40 and 64 years of age for breast cancer screening
- Between 21 and 64 years of age for cervical cancer screening
A smaller number of states extend similar benefits to both men and women dealing with malignancies affecting other body parts such as the prostate and colorectal organs.
Uninsured cancer patients can also qualify for Medicaid under the medically needy rules – if their state offers the program.[VI] This pathway helps people in one of the eligibility groups noted above who earn too much money to qualify otherwise.
A medically needy pathway allows possible recipients to spend down their income by subtracting healthcare expenses. The option works quickly for people who must pay 100% out-of-pocket for surgery, hospitalizations, chemotherapy, radiation and other treatments.
Medicare Under 65
Medicare is another government-sponsored health insurance program for cancer patients under 65. Medicare has three main parts that cover different types of services.[VII]
- Part A: covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, home health care.
- Part B: pays for doctor services, outpatient care, medical supplies, durable medical equipment, and some preventive services.
- Part D: covers prescription drugs
Cancer patients under the age of 65 can qualify for Medicare if they satisfy one of two conditions. Keep in mind that coverage begins in the month that you meet one or both standards, and Part A will be free. The costs for Parts B & D depend on state-level programs offering help with premiums.
- Received Social Security or Railroad Retirement Board disability benefits for 24 months
- Have End-Stage Renal Disease and meet other requirements