Health Insurance Coverage for BMT
In most cases, public or private health insurance plans will be the major source of coverage for your child’s BMT. It is essential that you find out right away if your plan offers a BMT benefit, and if so, the maximum dollar amount of coverage and the specific diagnoses and services covered.
It is important to understand that no legal requirement for insurance plans to offer any transplant benefit at all, although many do. It is not uncommon for plans to restrict BMT coverage to certain diseases or transplant types, or to deny coverage for procedures considered “experimental” (see more under Insurance Denials). Some insurance plans that do offer a transplant benefit, do not cover prospective donor testing of family members and/or search for an unrelated donor. Logically of course, except for autologous BMTs, there can be no transplant without a donor. Strong advocacy from your child’s oncologist and/or BMT center will be needed to resolve this matter.
Therefore, it is very important to get a copy of your actual insurance contract. This document is not the same as the general booklet or information brochure customarily given to plan enrollees; the contract spells out the terms of coverage, plan benefits and exclusions. If your child’s health insurance coverage is though your employer, you can ask for a copy of the contract from the human resources department or from the person who handles insurance for your company.
You also need to learn what type of plan you have–most commonly it will be either a group, individual, or self-insured plan. Knowing the type of plan is important not only for coverage information, but also because different federal and/or state laws regulate how each type of insurance plan functions. This in turn determines what rights policy holders do and do not have to contest any denials of coverage, and which government agency has responsibility for resolving coverage denials or disputes. This topic is too complex to discuss here, but you can learn more about types of insurance and related issues on the website of the Washington State Office of the Insurance Commissioner (OIC).
Educate yourself also about co-pays, deductibles, and patient responsibility percentages for all services, as well as about the lifetime maximum benefits offered by your plan.
For more information about health insurance and how it works, and special BMT help, the following resources may be helpful. In addition to information on types of plans, the Office of the Insurance Commissioner offers many helpful online and print publications, such as the comprehensive Consumer’s Guide to Health Care Coverage, which covers topics including finding insurance, and understanding and comparing policies. The OIC also offers a statewide toll-free telephone hotline as a for consumers experiencing health insurance problems, and a formal consumer complaint investigation and resolution service.
You may also find useful information in Consumer Guide for Getting and Keeping Health Insurance in Washington, from a nationwide series published the Georgetown University Health Policy Institute.
Insurance Tip: Ask that the company assign a case manager to your child’s case, if this has not already been offered. Children covered by WA Medicaid will be routinely assigned a case manager. S/he can serve as a single point of contact for handling all of the claims and insurance-related matters related to the BMT process. Case mangers can also help to request exceptions to limits of coverage, troubleshoot denial of claims and work pro-actively to coordinate coverage for services from multiple providers to ensure that your child receives the maximum benefits from the plan. Be sure to get the direct toll-free phone number and/or e-mail address of the case manager.
If a child was covered under a parent’s group health insurance plan, and the parent loses that coverage (due to unemployment, employer eliminating insurance coverage, etc) not only the parent but also an individual child is eligible to continue on the group plan under the terms of the Comprehensive Omnibus Budget Reconciliation Act or COBRA. Regardless of whether the parent elects to continue coverage under COBRA for his- or herself, a dependent child is eligible. COBRA extension is only available to those previously covered under group plans. The former employer cannot charge more than 102% of the actual cost of the premium (not the amount charged to employees, which may be subsidized). Request for COBRA continuation must be made within 63 days of the end of regular group coverage, and benefits last for 18 moths, or more under certain circumstances. Some patient families who can afford the premiums, have enrolled only their child undergoing BMT in a COBRA plan, both for the benefits and also to keep the child in a group plan so that s/he could later transfer to another group plan without having to meet waiting periods or exclusion for pre-existing conditions. For more on COBRA, see:
FAQs About COBRA Continuation Health Coverage
U.S. Department of Labor Employee Benefits Security Administration
Will I be able to get good health insurance in the United States?
Cancer Survivors Project FAQ #12
Insurance Company and NMDP Requirements for BMT Centers
You will also need to find out about any requirements of your child’s insurance plan regarding not only benefits for BMT, but also covered diagnoses, and which BMT facilities or physicians are covered under plan. Additionally, the NMDP facilitates unrelated BMTs only at facilities that are members of the NMDP Network. For most WA families this is not an issue, as CHRMC is the only pediatric BMT center in the state and it is part of the NMDP Network.
Note: In general this issue affects primarily adults undergoing autologous or related donor BMTs. On a national basis, some insurance companies may restrict coverage of BMTs to certain diagnoses and to transplant centers, which may or may not be part of the NMDP Network. The NMDP is involved with establishing quality standards for all types of BMTs. Insurance plans sold in WA State are required to have an appeals process by which members can appeal claims denials.
It is also a requirement that the donor’s work-up and marrow or peripheral blood stem cells harvest be done at an approved NMDP network facility. You may need to verify the coverage for donor services with your insurance company. The BMT center’s financial services representative will assist you with this process and can help you negotiate with the insurance company to cover special needs that might arise, such as if the need for the donor to travel to an in-network facility. If your child’s plan does not fully cover donor expenses, you will be advised of how much your responsibility is.
Transplant Insurance Broker Companies
You should learn if your insurance plan works with a transplant insurance broker company to negotiate a fixed-fee or a “global rate” contract for all or part of your child’s BMT. (For billing purposes, the procedure may be broken down into pre-transplant, BMT, and post-transplant components.) Many of the major insurance companies now do this as a way to contain costs both for themselves and ostensibly also for the policy holder. Under a global rate basis, the BMT, or the BMT phases, will be billed as a package or unit, instead of as separate charges for each individual service. This can reduce the total BMT cost by ensuring that all necessary care is covered, and can help maximize the dollar value of the patient’s transplant benefit. This follows the already common practice of insurance companies negotiating rates for specific services with medical facilities. The broker companies also may have their own networks of accredited facilities and participate in efforts of transplant medical professionals to establish and maintain quality –of-care standards. Some of the major BMT specialty insurance companies are Allianz LifeTrac, United Resource Network, and Interlink Health Services. Many of the major private general health insurance companies (e.g. Blue Cross Blue Shield, Aetna, United Health, etc.) have transplant networks as well.