¿Cómo afectarán los cambios en el seguro médico a las personas diagnosticadas con cáncer de mama (seno) metastásico?

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here's your host, Breastcancer.org Senior Editor Jamie DePolo.

Jamie DePolo: Thank you for listening. This podcast is the audio from a special virtual community meetup featuring cancer rights attorney and Triage Cancer CEO Joanna Doran. Joanna helped Community Director Melissa Jenkins lead this meetup on how health insurance changes can affect people with metastatic breast cancer. We hope this podcast answers some of the questions you might have.

Joanna Doran: Hi, everybody. I’m Joanna Doran. I’m the CEO of Triage Cancer and a cancer rights attorney by training. So for those of you who aren’t familiar with Triage Cancer, we’re a national non-profit organization that provides free education on all of the legal and practical issues that come up after a diagnosis. And a lot of those things are things you don’t think of as legal issues, like how to access health insurance, what your options are, how to compare those options, understanding your employment rights, managing your finances, but there are laws that can impact your options and give you eligibility for benefits and protections, and so at Triage, we provide education on what those laws say and how they impact your situation, specifically where you live. Because many of the laws are very location-specific, and so, I’m very happy to be here with you today.

Melissa Jenkins: Joanna, perhaps you could begin by giving us sort of a general landscape of the changes, as people are trying to decide or are struggling with the changes that might be happening to the overall insurance business, for people especially who are living with metastatic breast cancer, so who will be on ongoing medication. So, if you could give us sort of that bullet list of what the changes are and what people should be looking for, that would be very helpful.

Joanna Doran: Yes. Absolutely. So, a lot of these changes came about as a result of things that happened over the summer this year. So, we had Congress pass a large budget reconciliation act, which you may have heard referred to as the One Big Beautiful Bill Act, or OB3A or HR1. That reconciliation bill had a lot of information in it. So, it had information related to healthcare. There were changes to student loans. There were changes to taxes. So, that reconciliation bill contained a lot of information across lots of areas of our lives.

We did a webinar back in July that actually gave a very bare bones overview of some of those changes, and then, right after that bill, we got a number of regulations from different agencies that added some additional layers of changes on top of that bill. And so, those came out of HHS and the Department of Labor and a number of other agencies, and then we got some new rules that made changes to Medicaid and also made changes to the marketplace, and so, it was a lot of information thrown at all of us at once, and then, on top of that, a lot of those changes have actually been challenged in the courts, and they are currently working their way through the court system.

So, some of these changes may not even go into effect, because we don’t know the outcomes of those court cases yet. So, I just want to kind of give you that landscape and that everything I’m about to share with you is in flux right now, and we don’t actually know how a lot of these changes are going to play out. And the changes go into effect over a long period of time, so even into 2028. So, between now and 2028, there may be additional changes, and so those things might not actually get implemented the way that was originally included in the law that was passed this summer.

So, I just want to kind of give you the caveat that this is a very in-flux period of time, and we’re watching very closely to see how these things happen.

In addition to the fact that we had federal changes, these federal changes also have to be implemented at the state level. And the way that some of these changes were written is that it gives states flexibility in how they actually implement these changes. So now we have to watch how every single state might implement these changes differently. So with that, like, sort of foundation to the conversation, I want to kind of give you some of the headlines of what we think is going to happen, based on what we know so far.

So with respect to Medicare, that’s sort of the easiest to talk about at the moment. In Medicare this year, there were changes that happened from the Inflation Reduction Act that got fully implemented this year, where we saw an out-of-pocket maximum for prescription drugs under Medicare Part D that were capped at $2,000. Next year [2026], that amount goes up to $2,100, and only last week, or maybe a week and a half ago now, did CMS actually release the costs for Medicare for 2026. So, if you are on Medicare and you haven't seen that yet, those numbers have actually been released.

So, we’re actually working through all of our materials to make sure it gets all updated for 2026 numbers. Those are really the biggest changes coming to Medicare for next year in terms of how it affects patients and the costs that patients will be paying for care under Medicare. There are some changes related to who qualifies for Medicare because of changes to immigration requirements for Medicare. So there are some categories of individuals who have legal immigration status in the United States that may lose access to Medicare over the next year. So, in case you know anyone who might be in that situation, that is a change that is going into effect currently. So, that’s Medicare.

With respect to the marketplaces, that is actually where we’re seeing the biggest flux at the moment, because Congress is still choosing to decide whether or not they’re going to move forward with extending the additional premium tax credits in the marketplace. So, I’m going to back up a little bit and explain what that is for everybody’s benefit.

The state health insurance marketplaces that are available in every state, the way that they operate is that the government basically built a shopping mall in every state for people to go to to find individual health insurance plans sold by private insurance companies. All of the plans sold in the marketplace have to comply with the consumer protections that were in the Affordable Care Act.

So, there are some benefits to buying coverage through the marketplace because you have access to those protections. There is also financial assistance available to get access to plans in the marketplace, based on your income level. And there’s two types of financial assistance. So there are marketplace premium tax credits, which lower what you pay for your monthly premium, based on your income level. And then there are cost-sharing subsidies which lower what you pay or some of your out-of-pocket costs. So things like your co-pays, and your deductibles, and your co-insurance amounts. That financial assistance existed when the marketplace was created.

Then COVID came along, and it was important that everybody had access to health insurance coverage, to make sure that people were getting access to healthcare during the pandemic. And so the federal government passed the American Rescue Plan Act, which added financial assistance to the marketplace. So it made it more affordable for people to actually get plans through the marketplace by helping lower those monthly premiums. And then the American Rescue Plan Act, because it was a COVID bill, was time limited. So, it expired during the pandemic and then it was extended by the Inflation Reduction Act through December 31, 2025.

So in a few weeks, that additional financial assistance is going to end. The original financial assistance will still continue to exist, but it is much less than what was created by those two additional bills. And so for many people, that is going to increase the cost of their marketplace plans, sometimes by tens of thousands of dollars, if their whole family is covered by a marketplace plan. So we know that millions of people are no longer going to be able to afford their health insurance coverage if the financial assistance sort of ends on December 31.

So everybody is very concerned because open enrollment is going on right now for the marketplace and people don’t have a good sense of what their plans are going to cost them for next year, without knowing if that additional financial assistance is going to be available. So the congressional argument over whether or not to extend these subsidies is actually what led to the government shutdown. So now we have the government shutdown ended, but we don’t have clear information from Congress yet about what they’re actually going to do. So that’s a big what-if.

So that’s going to affect millions of people in terms of how they’re going to have access to health insurance coverage next year. One of the things that we’re concerned about from the advocacy community, is that if people can’t afford the marketplace plans, which come with those consumer protections, what are their other options for health insurance? And the answer is there are not that many other options. So if you are looking in the open market for health insurance, one of the things that you might come across is a short-term health insurance plan.

These are plans that don’t have to comply with the ACA consumer protections, but seem very attractive because they have a low monthly premium. They’re also not marketed well as a short-term health insurance plan. So people don’t realize that’s what they’re buying and then they are diagnosed with a medical condition like cancer, and then they go to get care, and they find out that it doesn't cover chemotherapy or it doesn't cover hospitalization or it doesn't cover prescription drugs. And unfortunately, in those circumstances, they don’t have to. They are allowed to exclude categories of care, or they can deny people based on pre-existing conditions, or they can change people more based on a pre-existing condition, and they’re short term. So they’re only for a specific period of time. So even if you can get one of these plans with a pre-existing condition, if you start to use the plan, they might notice, frankly, and say, okay, we’re not going to renew this plan when it comes up for renewal. And then you’re left in the middle of the year without health insurance, and it doesn't trigger a special enrollment period to go buy a plan in the marketplace.

So there’s a lot of worry about people purchasing these plans and not realizing that they don’t have to comply with all of these consumer protections. And then, basically, being left uninsured, because it doesn't actually cover anything you need care for. So, I put that caveat out there because we know that these plans are much more available than they used to be and that they’re marketed in a way where it’s not clear what they are. But the reality of the situation is that if somebody can’t afford a marketplace plan, these plans might be their only option for insurance.

So it creates a very really unfair situation, where somebody might be feeling like this is their only option, but it’s really not that great of an option. So I don’t necessarily have a good answer for that one. I just want people to be aware that that’s something we’re seeing and that if people are shopping for plans outside of the marketplace, to ask some questions about what types of plans those are that are being sold.

So maybe, Melissa, I’ll stop there and ask if there are any questions related to Medicare and the marketplace before we move on to maybe Medicaid?

Melissa Jenkins: Does anybody have a question that they’d like to raise?

Sharon: Actually, I do. This is Sharon.

Joanna Doran: Okay, yes?

Sharon: Hi. Thank you for the information so far. I have a question...I’m sorry, I don’t want to get specific about myself, but just for people who are going to be going on Medicare, say, and they have to buy the gap plan, would that be something that the marketplace...like, is that what you’re referring to when you talk about the marketplace or these other options that you just went over?

Joanna Doran: That’s a really excellent question. So you cannot buy a Medigap plan, which is a Medicare supplemental plan, through the marketplace. If you want to buy a Medigap plan, you actually have to go straight to the Medigap plans that are sold in your state. But if you’re looking for what those plans are, if you go to Medicare.gov, which is the Medicare federal government website, and there is a Medicare plan finder tool on that website, but there’s also a Medigap plan finder.

So, you can put in your zip code where you live, and it will show you the plans that are available in your state, but then you do have to contact the plans to see if they will sell you a plan. When you first become eligible for Medicare, you have what’s called a guaranteed issue right to a Medigap plan, meaning they cannot deny you. But if you wait until outside of your initial enrollment period, they can actually either deny you based on a pre-existing condition or impose a pre-existing condition exclusion period, where they won’t cover your care for up to six months related to your pre-existing conditions, or they can charge you more.

So those pre-existing condition protections I mentioned that were in the ACA, they actually don’t apply to Medigap plans. They were specifically carved out of the ACA. That said, for people who are becoming eligible for Medicare under the age of 65, because you have a disability and have access to SSDI, the Medigap rules are different for individuals under 65, and it’s state-specific. So in some states, plans are not required to sell Medigap plans to individuals under the age of 65. So there are some states where you can’t get a Medigap plan if you're under 65. That said, the rules are very specific, and we do actually have that information on our chart of state laws at triagecancer.org. So, you can find the information specific to your state.

Sharon: Okay. Great. Thank you so much.

Joanna Doran: Of course.

Melissa Jenkins: Carol?

Carol: Hi, thank you. You pretty much answered my question. I was just wondering if they’re state-specific, because there’s a lot of feedback that I get when I’m on Breastcancer.org on that support group, and then I look into it, and I get this information, and people...you know, they’re trying to be helpful, and I appreciate that, but you know, they’re talking about, like, Texas or Illinois, and it’s not the same in New York, you know? I’m like a dog chasing my tail around, and so, what I wanted to specifically ask you is that I got approved for disability at the end of July or beginning of August, but I still have not heard about Medi...

Joanna Doran: Medicare.

Carol: Care. So, because I have a disability, I will get that here in New York State?

Joanna Doran: So once somebody has been receiving SSDI benefits for a full two years, then they become eligible for Medicare. But the timing of how that actually works out is kind of complicated in terms of how they figure that out, because they go back, and they look at when was your disability onset date? So, that’s a term they use to say when was the first time you were unable to work because of your medical condition? So, even if you were approved today, for example, they might look at your situation and the specifics of it and say your disability onset date started a year ago.

Then they actually make you wait five whole months before you receive your cash benefits. So it’s a five-month waiting period. So they’re going to take that five-month waiting period out of that one year ago that your disability onset date began. So then, they’re going to say, okay, well, you were first eligible for cash benefits seven months ago, because they take out the five-month waiting period. And then, two years from seven months ago is when your Medicare coverage will begin.

So, it’s not always totally linear that it makes sense when Medicare begins, but Medicare always starts from your entitlement date, which is the first day you were eligible for cash benefits. So if this sounds confusing, it totally is. We actually have a quick guide to the timing of SSDI and Medicare benefits that explains this timeline so you can actually do some math, based on when Social Security told you your disability onset date was in your award letter. So, then you can figure out when you actually will be eligible for Medicare.

Carol: Okay. I thought I was going to have to go onto COBRA, and I was told by my union, because I work for New York State, and one of the things that they said to me is that because I’m on disability, I’m still entitled to get my health insurance, which doesn't sound right.

Joanna Doran: It is possible. So you had a situation where, because you’re a member of a union, that union bargaining agreement might give you additional benefits and protections, and one of those benefits might be that they will continue to pay for your health insurance coverage without making you go on COBRA. So that’s an additional benefit that is specific to your union, not under a different type of law.

Carol: Okay. Thank you. I appreciate it.

Joanna Doran: Of course.

Melissa Jenkins: Are there any other questions currently? Then let’s move on, Joanna.

Joanna Doran: Okay, and certainly, if others come to mind, feel free to let me know. So the sort of elephant in the room for the advocacy community are the changes that are coming to Medicaid. And Medicaid is the federal health insurance program that is available for individuals who have a low income level and generally meet other categories of eligibility. The thing about Medicaid is that people don’t realize it covers 25% of people in the United States. So one in four people in the United States get their health insurance coverage through Medicaid, and that might be that they only have Medicaid.

It might be that maybe they had other health insurance, but now they’re getting access to long-term care coverage. Like, they’re in a nursing home and that is what’s paying for nursing home care. It might be that somebody has access to Medicare and Medicaid. So Medicaid actually reaches and touches a large portion of our population. Medicaid is a federal program, but it’s administered at the state level, and it comes together by federal funds and state funds. Even though it’s a federal program, states can also customize their Medicaid program by applying to the federal government through a waiver program.

So they apply for an 11-15 waiver to customize their program. And states can sometimes do really creative things. They might say, you know, we believe that food is medicine, and we want to create a nutrition program in our Medicaid program. So just as an example. So states can actually customize their programs, so it’s a little bit hard to talk about Medicaid across all states, because there are state-specific differences.

That said, the Medicaid program was changed by the Affordable Care Act. So, generally, people would need to have a low income level and a low resource level, meaning their assets, and they had to meet another category of eligibility. So it might be that they’re senior. It might be that they’re a child. It might be a woman who’s pregnant, or it could be an individual who has a disability and was approved by the Social Security Administration under the SSI program, Supplemental Security Income. There are a lot of different doors into the Medicaid program. It does also include the Breast and Cervical Cancer Treatment Program, so that’s a separate door into the Medicaid program. The Affordable Care Act created a new door into Medicaid, and that door was only based on income level.

So for anyone with a household income level up to 138% of the federal poverty level, which this year is about $21,000 for an individual...so, if you make under that amount, you can get access to Medicaid in your state. Except that after the Affordable Care Act was passed, the Supreme Court, through a court case, made it voluntary for states to participate. And so 41 states, as of today, expanded access to their Medicaid program by creating this new door and 10 states have not. So the new door is referred to as Medicaid expansion. And a lot of the changes that happened over this past year are focused on the Medicaid expansion population. So the people who have gotten access to Medicaid through this door.

One of those big changes is that there will now be a work requirement if you want to get access to Medicaid through that door. Now the work requirement is something that other states, over time, have tried to implement and actually were struck down by the court systems. So Arkansas is an example of a state that had a work requirement program and it was struck down by the court. Or recently, Georgia actually did implement a work requirement program, and it hasn’t significantly given people access to health insurance coverage through that program. So they were expecting tens of thousands of people to be able to apply through this program. There’s been very low enrollment numbers through the program.

We’ve also gotten data over the years that’ve showed us that these work requirement programs don’t actually increase the number of people who are working and are in the Medicaid program. So I won’t get too far down the rabbit hole in terms of what we know about work requirements that have been implemented in the past, except that they’re not all that effective at, A, increasing people’s ability to work, or B, getting people access to health insurance coverage.

In fact, what we know is that people lose access to health insurance coverage through these work requirements, because people don’t actually submit the paperwork to prove that they still qualify, even when they do still qualify. And there’s a variety of reasons for that. When you think about the Medicaid population, if it’s individuals who are older or maybe don’t have access to the internet or lower literacy levels, there’s so many reasons. People move, and then they don’t get the paperwork, and so they don’t turn in the paperwork. So, there’s all these logistical hurdles to actually keep access to your health insurance coverage and that’s actually why people lose coverage.

So when people talk about the work requirements and the millions of people who are going to lose health insurance coverage through this program, it’s not because they don’t still qualify. It’s because they’re very likely to not actually submit the paperwork. And that’s just based on what we know historically. So with the work requirement, it is not just work that you have to do in order to keep access. The work requirement is sort of this umbrella term that doesn't necessarily mean work. It could mean that you are volunteering or engaging in community service projects. It could mean that you’re going to school, at least part time. It could mean that you’re in a work training program.

So there’s other things that can help you meet the work requirement. And the way that the big bill’s requirement was written is that you have to work at least 80 hours a month and do one of those many things. On top of those many things that you could do to meet the work requirement, there are also exceptions. And the way that the exceptions are written is it’s, like, a bullet-pointed list of things, but we don’t have definitions yet. So there’s a bullet that says medically frail individuals don’t have to comply with the work requirement. But what does medically frail mean? Like, that’s a very specific use of language that we don’t have a legal definition for.

Does that mean that you have to qualify as having a disability under the Social Security Administration and be getting SSI or SSDI? Does that mean that states can create their own definition of medically frail? Does that mean...you know, we don’t know what that means yet. And the reality is, is that the federal government still has to release regulations that flesh out these definitions, and they aren’t expected to release those regulations until June of next year. So we have to basically wait until June to get some of this information, unless they act faster. But that, generally, doesn't happen. So, there could be an exception. There is very likely to be an exception for individuals who have serious medical conditions, but we don’t have a definition of what that is yet.

There are also exceptions for parents of children under the age of 13. So if you have a young child at home, you are exempt from the work requirement. If you're a senior, you’re exempted, so if you’re 65 or older. So there are a list of exceptions. We just don’t have the details on what some of those things actually mean yet.

This is all supposed to be in effect in every state by January 1, 2027, except that there are some states that might be able to get an exception, because it’s a lot of work for states to actually create these systems and to implement them and to communicate with people.

So states, if they have a justifiable reason for delay, they have an exception until the end of 2027. So it needs to be in effect by 2028. So everybody’s looking at this right now as something that’s going to start in 2027, except there are about 15 states that would like to do it faster. So we see, in Iowa, for example, the Iowa governor said I want this to go into effect January 1, 2026. So if you look at Iowa’s Medicaid website right now, it does talk about work requirements, and it looks like, based on what’s there, it will start January 1. And so the first time that somebody has to report will be June of next year. So some states are moving forward with this process faster than what the federal government is doing.

And so it is something that we’re watching very closely to see what’s happening, so that we can make sure to communicate with people, this is happening in your state, and you need to be paying attention. Even down to being able to tell people, the notices are being mailed out this week. They’re on yellow paper. They’re coming from, you know, this entity. Make sure you’re looking in your mail for this. Or it’s going to be an email to an online portal. We don’t have that information yet, but as soon as we do, that’s what we’re going to start pushing out, to make sure that people know what the process is in their state, so that they can comply with these new requirements.

The other piece that is going to be state-specific, is that the federal government used to require the Medicaid programs to check once a year to see if people are eligible. So you basically have to renew once a year for your Medicaid coverage. The new law requires that to happen twice a year. So every six months, people will have to confirm that they are still eligible for Medicaid and go through this reporting process to show that they have met the work requirement and they continue to meet the financial requirements, for example, of income level. So this is going to happen twice a year for people, which is an additional hurdle that people have to meet to make sure they keep access to coverage.

So that’s what we’re looking at, kind of big picture for the Medicaid changes coming down the pike. There are some, like, nuanced things, and there are changes about how Medicaid is going to reimburse states and state Medicaid programs for various things. But from a patient perspective, that’s really the biggest thing that we’re looking at, are the work requirements and communicating that it’s not just going to be a work requirement, but it’ll also happen twice a year, and then how you actually make sure you’re submitting the paperwork. So, those are sort of the big things coming down the pike, and that it might happen before January 1, 2027.

Melissa Jenkins: Mika?

Mika: Hi, thanks so much. This has been incredibly helpful. Without trying to be too specific about my scenario, I have metastatic breast cancer. I am on SSD. I’m on a holding period of the two years, until December of 2026. I’m going to be losing my private benefits through my employer in December of this year. So I have 12 months that I need to find coverage. So now that you’ve covered kind of the options, is there anything I’m missing? It doesn't seem like there’s much available then, if you’re in that holding period. And I saw the explanation that I put in the chat, why there’s the two-year waiting period. That seems crazy to me, because most of us that are in this scenario won’t have benefits for two years because we’re on disability, so that means we’re not working.

Joanna Doran: Yes, I actually think the waiting period for SSDI and the waiting period for access to Medicare, I often say it’s the thing that makes the least amount of sense in all the laws and programs that I talk about on a regular basis. Because you can’t be working, so you have no income coming in and you’re not able to work, and then we wait five months, which really is the sixth month, because the benefits don’t arrive until the sixth month, without any help coming in. So it creates a lot of really very practical challenges for people in that circumstance, and so, I agree. It doesn't really make a lot of sense. But you’re right, in that if you’re trying to fill that gap between when employer coverage ends and when Medicare kicks in, there are limited options, but there are some options, more so than existed before. So, COBRA would be one.

Mika: My COBRA is $845 a month.

Joanna Doran: Which I understand seems obscene, but I’m going to share a couple things to maybe keep in mind. So you can look at the marketplace to see what your options are in your state. I think that it’s a little hard to tell what’s going to happen with actual costs for the marketplace. So you might actually want to look at the marketplace in your state, looking at this year, as if you were going to be eligible this year, and then also look at next year and what the price differences are, if that gives you some perspective on what might change if Congress does actually pass something. The other piece about the analysis of figuring out what costs look like, if you already met your deductible and your out-of-pocket maximum for 2025...

Mika: Which I did.

Joanna Doran: So this doesn't really help you out, now that I’m thinking about it, in December, because December doesn't really help you.

Mika: It actually does for me, because my fiscal year is July 1 to June 30. So, I actually did have six months left once I’m inactive.

Joanna Doran: Okay. Then my example will still work for you. So if you are in the middle of a plan year, the math involved in figuring out what something is going to cost you...if you’ve already met your out-of-pocket maximum, your math for the rest of your plan year is only going to take into consideration your monthly premiums, which I know are high, but hang with me for a second. The alternative is looking at the marketplace plan and seeing...if you’re in the middle of the year, getting a new plan basically means not only are you paying the monthly premium for that plan, but you’ll also have to meet your deductible and your out-of-pocket maximum again for that new plan option.

So when you’re doing the math to compare your options, those are the things that you have to take into consideration. So any time we’re talking about figuring out what a plan is going to cost you for the year, you take the monthly premium and you multiply it by 12 or however many months left in the year you have on your existing plan, and then you add that to the out-of-pocket maximum for the plan that you’re looking at, because when we’re talking about ongoing medical care, like, for individuals with metastatic breast cancer, you’re going to hit your out-of-pocket maximum.

So that’s the key piece that’s often missing when people are comparing costs, because they’re just looking at monthly premiums and not also taking into consideration that out-of-pocket maximum. So that said, there are some financial assistance resources, and there are some in the chat, actually, about helping to pay your health insurance premiums. With COBRA specifically, there is also a state Medicaid program where, if somebody has a group health insurance plan, like COBRA, for example, and they also qualify for Medicaid in their state, based on their income level, they can actually go to the state Medicaid program and say, I want to apply for Medicaid, but I want you to pay my COBRA premiums for me, rather than pay for all of my care through the state Medicaid program.

The state actually does the math to say is it fiscally better for us to actually just pay the monthly premium for this individual’s COBRA premium, rather than to pay for all of their care under the state Medicaid program? And generally, it’s cheaper to pay the monthly premium. So this Medicaid program is called the Health Insurance Premium Payment program, or HIPP. So the HIPP program, it may be called something slightly different in every state, but it’s an optional benefit. So not every state Medicaid program offers it, but on our chart of state laws, if you look for Medicaid under our chart of state laws, we tell people which states have the HIPP program and then also link to that information for the state.

So this is actually...I say all the time this is a very well-kept secret of our healthcare system, because it’s a very useful way for people to keep their COBRA coverage and have the state pay their premiums for them, rather than to be concerned about moving to Medicaid coverage and potentially having to change providers, or will the providers be covered, or will my formulary change for my prescription drugs? So it’s a good way to actually have, to keep COBRA and have the state pay the premiums. So, in case that is helpful to anyone.

Mika: Thank you. Unfortunately, I don’t qualify for Medicaid. I am in Texas, which, as we know, has some pretty crazy rules associated with this. So, yeah, it sounds like I either pay out of pocket for the COBRA or I have to go on an Affordable Care plan.

Joanna Doran: These do seem like your options in Texas. There continue to be additional financial assistance programs that are dropped in the chat. I will also say, at Triage Cancer, we have a tool called cancer finances, which also has financial systems resources that we have gathered, where, if you’re looking for different types of financial assistance, you can find that there. So it’s Cancerfinances.org.

Any other Medicaid questions or maybe something else we haven't talked about yet?

Melissa Jenkins: I’m wondering if people have questions about, perhaps, Medicare Part B and D and anything else they should be considering specific to these parts?

Joanna Doran: Maybe while people are thinking about their Medicare questions, I will just say that we have a two-part series on Medicare. We did one in October around open enrolment to help people make Medicare choices. We do have the second part of that series coming up on December 4, which will be more about, if you have Medicare, the ongoing things that you need to be aware of related to your Medicare coverage. So that is free, but they also get recorded and shared on the website, so people can watch those at any time. And we have a lot of resources to help people understand the choices around Medicare coverage when you first become eligible, especially because there are really two very different options about how to get access to coverage, and sometimes, when you first become eligible, you have some key choices to make that affect your choices downstream, including around access to Medigap plans.

Melissa Jenkins: Carol, did you have a question?

Carol: So I think you sort of answered my question. So as I said earlier, I have not been approved for Medicare yet. I’m expecting it to happen. You know, when it does happen, will I then have, like, a time period to make those decisions about what I want, if I want to get the Advantage Care and I want to do that? So, they do give you...how long do they give, usually, to make that decision?

Joanna Doran: So, your initial enrollment period lasts seven months. The three months before you become eligible, the month in which you become eligible, and then three months after. So generally, we try to get people to make decisions before they become eligible, because then their coverage will start the first of that month. So if you are in that situation, I would definitely recommend taking a look at the information we have on those Medicare choices. We also have a legal and financial navigation program where we answer people’s one-on-one questions. So if you have questions about your Medicare choices, at that point, you can contact us and set up time to talk with our team for free.

Carol: So Joanna, I want to say I’ve really loved this, and Triage Cancer Care has been recommended to me, and when I was doing my disability and I didn't know about what to do and I didn't know about the healthcare, people suggested it, because people on that website really love Triage Cancer Care, and I have to say, I called no less than five to six times and no one ever called me back.

Joanna Doran: So I will tell you that that does not happen at Triage Cancer because we track everything, but I will tell you that if you call and leave a message, that creates a situation where we play phone tag with people. So the best way to contact us at Triage Cancer is to actually go to our website at triagecancer.org/gethelp, and if you fill out a form with your information, it sends you an automatic email where you get to pick a time off our calendar that works for you to set up an appointment to talk with one of our attorneys. So that is the fastest way to get connected with us, but if people don’t have internet access, they can call, but we call multiple times to call people back. We text multiple times to try to get people to give us an email address so that we can also follow up by email to make sure that we get an appointment scheduled. So, I will assure people that if you reach out to us, we will try our best to get a hold of you, but you have to call us back.

Carol: I did all that you’re describing and nothing. I didn't hear from anyone. No one called me. No one emailed me.

Melissa Jenkins: Something definitely happened.

Joanna Doran: I’m definitely sorry to hear that, but I would say that if you sign up today through the form on the website, you will get a call back.

Carol: Okay. Thank you.

Joanna Doran: Of course.

Melissa Jenkins: Sharon? "I am 65 and have Medicaid Advantage, but still on my husband’s work insurance, but he’s retiring soon. Would it be better to sign up for Medicare B now, in 2025, rather than in 2026 so I’d be in the system? I know that cost changes every year, of course, Medicare A."

Joanna Doran: So Sharon, it’s really up to you. So you could decide right now to sign up for Medicare Part B when it will go into effect January 1, because Medicare coverage is calendar coverage, but you will also have a special enrollment period when your husband actually leaves his job. So when he retires and the employer-sponsored health insurance plan ends, you have a special enrolment period to come back to Medicare and basically pick up Medicare Part B. You can also pick up Medicare Part D, or you can choose to have your coverage through a Medicare Advantage plan, which is Medicare Part C. You also have a special enrolment period to pick up a Medigap plan at that point in time, as well, and you don’t face any late enrolment penalties, as long as you make all those choices during the special enrollment window. So as long as you do that then, then you don’t actually need to sign up for Part B now if you don’t want to.

Sharon: Okay. Yes. Thank you. I did pretty much know that. I was just curious as to whether or not being in the system before 2026, even enrolling, would be helpful, even as the cost changes. I understand that, but I’m afraid if I wait until, say, January...he’s going to retire really soon. So if I wait until 2026, January, would that even make a difference? Because I would already be a recipient, or at least started the process.

Joanna Doran: There’s nothing really specific that would make it better for you to sign up now, unless you want that additional coverage, but then you need to make sure that you communicate with the employer-sponsored plan, because the way that employer plans and Medicare interact are very specific, and so, there’s a coordination of benefits process. So you want to make sure they know that you’re going to do that, and you want to know how they interact and how they’re going to cover things. But I would say that, for example, if he’s going to retire on February 1, you could actually even sign up, like, start the process to sign up so that February 1, when he loses his employer plan, your coverage would begin on February 1.

Sharon: Right. Right. I do have the forms to submit to the employer. So I do know that, but I just wanted to kind of throw this out, and I don't know if you come across this with what you do, but I was told if you have cancer, it’s really not a good idea to go on a Medicare Advantage Plan, because they’re nice and pretty, and they give you a lot of extras, and then when you find out you need chemo...or whatever the case may be, as a cancer patient, it’s not so great.

Joanna Doran: So there are pros and cons of choosing to get your Medicare coverage through original Medicare, which is a fee-for-service program, meaning that you can go to any provider across the country who accepts Medicare, versus choosing to have your Medicare coverage through a Medicare-managed care plan, which is that Part C Medicare Advantage plan, because in those managed care plans, you are agreeing to get coverage to see a specific network of providers. So, when we’re talking about cancer care, if you need to see a specialist or if you want more flexibility in which providers you’re going to, then you may not want a Medicare Advantage plan. I will also just say that there are many cancer centers we are seeing across the country who are now refusing to accept Medicare Advantage plans. So when you’re thinking about that decision, you might want to be looking at your providers, or if there are hospital systems that you go to, to check to see, with them, if they are actually included in the Advantage plans that you’re looking at.

Sharon: Yeah. Thank you so much. It’s been really helpful.

Joanna Doran: Of course.

Melissa Jenkins: Are there any other questions? Specifics?

Joanna Doran: So, there was a question around infusions for metastatic breast cancer being covered under Part B Medicare, and I just want to clarify something, because depending on how you receive a prescription drug or a treatment will determine which part of Medicare it actually gets covered under. So chemotherapy, for example, if you are an inpatient in the hospital and you’re receiving chemotherapy, that’s generally going to be covered under Medicare Part A, the hospital insurance side of Medicare. If you’re receiving an outpatient IV infusion, that’s generally going to be covered under Part B. But if you’re taking an oral chemotherapy, for example, that might be covered under Part B, or it could be covered under part D. So even when we’re talking about just one type of treatment, it still can be confusing in terms of how Medicare is going to cover it. So if you have questions about that, those are questions for your healthcare team about how they bill for certain types of treatments that you might be receiving.

Melissa Jenkins: That leads me to the question of, because people frequently have to change their treatment, should one have all three parts in case they have to switch treatments?

Joanna Doran: That’s a good question. So generally speaking, when we’re talking about insurance, we don’t have a crystal ball, right? We get insurance in case something happens to us, right? So we get car insurance in case we get into an accident. We don’t wait until we’re in a car accident and then buy auto insurance. So I think sometimes we forget about that in the context of health insurance. The problem is that insurance companies are allowed to change their formularies whenever they want to. So we make decisions purchasing plans based on the formulary list of drugs that they cover today, but tomorrow that could change.

So if somebody's in their situation where their plan no longer covers their specific drug on the formulary, there are processes that you can actually go through to keep access to that drug. And that is something that your healthcare team might help with, but if for some reason they don’t, there is something specific to Medicare called a Medicare Exception Request, where people can actually request an exception to the formulary. And so there is a specific process for that, and we actually have a quick guide that walks somebody through the steps for that process, but the same concept exists in other types of insurance, as well.

You can ask for exceptions to the formulary to keep access to drugs that are the most appropriate for you, and then there’s certainly also the appeals process, and we have lots of resources to help people navigate appeals.

But in terms of your question specifically, Melissa, if somebody is looking at making Medicare decisions for the first time, for example, Medicare Part A is only covering hospitalization. It does also include some coverage for hospice care and some coverage for home health care and skilled nursing facility or nursing home care when somebody leaves a hospital setting, but Medicare Part B is what we call medical insurance.

So it’s the biggest core of Medicare coverage because it covers outpatient care and doctors’ visits and bloodwork and imaging scans and durable medical equipment and IV chemotherapy. So it’s the biggest kind of chunk of Medicare coverage, and Part A and Part B together are what we call original Medicare, because that’s what existed when it was signed into law in 1965. So that doesn't include prescription drug coverage. So if you want prescription drug coverage, you also have to look at a Part D plan, which is sold by a private insurance company. So, you have to go look at what your options are.

Then if you want help covering out-of-pocket costs that Medicare doesn't cover, then you might consider a Medigap plan, which is supplemental coverage to pick up those additional out-of-pocket costs.

On the other side, you can choose to have Part A, Part B, and Part D coverage through a Part C Medicare Advantage plan, which is also sold by a private insurance company and is a managed care plan. So, we talk about it as two different lanes you can drive down related to Medicare choices. And again, as I mentioned earlier, there are pros and cons to each lane, but those are really the two differences. So generally, we wouldn't recommend to somebody to only have one part of Medicare because then you really don’t have full-scope coverage.

Melissa Jenkins: Excellent description and excellent information, Joanna. We so appreciate you today, and Joanna, thank you. Thank you.

Joanna Doran: It’s been my pleasure.

Melissa Jenkins: And if anybody else continues to have questions, please know that Breastcancer.org will be happy to help, along with Triage Cancer. So, whatever we can do to help the process. Thank you. Thanks for all coming, and again, thank you, Joanna.

Thank you for listening to The Breastcancer.org Podcast. Please subscribe to Apple Podcasts. To share your thoughts about this or any episode, email us at podcast@breastcancer.org or leave feedback on the podcast episode landing page on our website. And remember, you could find out a lot more information about breast cancer at Breastcancer.org, and you can connect with thousands of people affected by breast cancer by joining our online community.