[Narrator]

Another federal program that helps pay for some cancer-related expenses is Medicaid. Medicaid pays for a defined set of services for low-income people who are elderly, blind, disabled, receive public assistance, and even people who have low-paying jobs. Most of these people fall outside of the groups who qualify or can afford other kinds of insurance. Medicaid, like Medicare, is administered by the Centers for Medicare and Medicaid Services, sometimes just referred to as "CMS." Each state decides who is eligible for Medicaid, decides the type, amount, and duration of services it will pay for or cover, decides how much it will pay for services, and administers its own program. But, regardless of each state's decisions, federal law demands that every state's Medicaid program covers inpatient and outpatient hospital care, nursing home care and home healthcare, and care given by doctors, midwives and certified nurse practitioners. Medicaid must also pay for laboratory and X-ray services, screening services, diagnosis and treatment for people under 21 years old, and care given by rural health clinics and other government supported community health centers. Medicaid pays Medicare premiums and some other cost-sharing requirements, and pays for prescription drugs for certain low-income elderly people and others who are disabled. People must apply to the Medicaid program in order to be eligible for medical coverage. Application for Medicaid can be made at a local Medicaid State agency, or the hospital social worker can help with the application. Qualifying for Medicaid help is based on several factors, including a person's assets - that means what you own, what you have in bank accounts, stocks or cash - and income. The rules are different from state to state. The social worker can help cancer survivors and their families assess their likelihood of getting help from Medicaid. Lydia describes the assistance she and her family were able to receive from Medicaid.

[Lydia]

I was 39, a full-time housewife and mother, when I found out that I had colon cancer. My husband works, but our income is still pretty meager, and his job does not offer health insurance benefits. We have three great kids - they are 10, 7, and 5 years old. So, I am always very busy, and I usually have a lot of energy. But, the cancer and the chemotherapy have made me feel so tired all of the time. The social worker invited me to come to the support group, but I told her that I could not spare the time away from my kids. She was so understanding - and she took the time to talk to me alone. I told her that I was feeling very weak and tired, and that I was afraid that I was not watching the kids like I should. We cannot afford to hire a baby-sitter, and we do not have family close by. I felt so sad all the time - like I was letting down my family and not being a good mother. I also could not see any way for us to keep paying for the entire six months I am supposed to have treatment. We needed help. The social worker met with me and my sister-in-law. When we looked at the rules, we saw that our family income is just about $100 over the requirement for Medicaid. The social worker told us about the option of paying the $100 directly to Medicaid each month in what they call "share of cost." This way, through Medicaid, I would have the insurance I would need to continue my chemotherapy treatment. My husband and I met with the Medicaid case worker, and it seemed like this plan would work for us. We worked with a case worker to see if we would qualify for other services.

[Narrator]

Medicaid has other provisions that can help families deal with the expenses of chronic illness. Some cancer survivors need at least temporary, and sometimes long-term nursing home care. The expense of care in these nursing care facilities can cost in excess of $5,000 every month. These costs can deplete the lifetime savings of older couples. In 1988, the U.S. Congress made some changes in Medicaid that prevent what is called "spousal impoverishment" - leaving a spouse who is still living at home with little or no income or resources. These provisions apply when one person in the couple is in a nursing home and is expected to stay there for at least 30 days. Again, the social worker, financial counselor, or the local Medicaid State agency can help couples use this benefit when it applies, and make sure that a couple's home and resources are protected. While Medicaid does pay for many services for low-income people, there are things that might be important to some, though not all, cancer survivors. Janet's story provides an example of finding ways to get care that was not available through Medicaid - or by the way, might not be available through managed care organizations - sometimes just referred to as "MCOs", HMOs, or other private insurance plans.

[Janet]
 
Well, I have been a night-club singer ever since I came to The City. I have always loved it. I have a couple of recordings out, and I have even written some of my own songs. But, like many singers, songwriters, and other kinds of independent and struggling artists, I don't have a regular job and I do not have health insurance. I always figured I was too young and too healthy to get sick. So, imagine my surprise when I found out I had breast cancer. My income was - and still is - very limited. Oh, I make enough to get by, but that's about it. So, I didn't have a problem qualifying for Medicaid. I had to have a mastectomy - surgery to remove my entire breast. My tumor was too big to be removed by a simpler operation such as a lumpectomy. At first, I only cared about getting rid of the cancer - I didn't give a lot of thought to what I'd look like or how I would feel after the surgery. But, once I got through treatment, and I wanted to go back to work, I was so depressed by the constant reminder of my cancer when I went to work. Work was always my wonderful escape - but now, I couldn't disguise or even forget for a moment that I had cancer: I couldn't wear the low-cut gowns that I usually like to wear and, that I think, are important to my career as a torch singer. I just didn't feel good about myself. I had talked to my breast surgeon about reconstruction, but Medicaid - at least in this state, considers breast reconstruction to be cosmetic surgery. Ha! - Cosmetic?! For me, how I look is how I feel about myself - as a woman - and as far as I am concerned, is important to my career. One day, I dropped by the hospital to talk to my cancer nurse, and she noticed that something was bothering me. I had been so excited about going back to work - but I guess she saw that now, I wasn't that thrilled about it. Anyway, we talked and I told her everything. She didn't make any promises - other than that she would see if there might be some kind of special fund somewhere in town - maybe in a teaching hospital - that would help me get breast reconstruction. It was really something -- she actually found a program in the community hospital where I had my surgery. They have a training program right there for plastic surgeons, and specialize in offering surgery to cancer survivors who wanted reconstructive or restorative surgery. It became sort of a negotiation process. If I would agree to have a plastic surgery resident do my operation, the fund would pay for the surgery and all of the follow up care. My nurse helped me make sure that the doctor who would actually do the surgery was qualified, and that the doctor who runs the training program would be right there to supervise. I was reassured by my nurse's confidence in the surgeons, and the reconstructive surgical team. For me, everything turned out just great. I know that some women don't feel they need to have breast reconstruction - or they just don't want to go through this. But, I did. It was important to me, and it was worth it. I had the surgery, I like my image in the mirror and feel good about myself. I'm back to singing - in my favorite dresses.

[Narrator]

Janet had given a lot of thought to what her needs were, and she finally told someone who wanted to help. Together, they explored the options that were there for Janet, and then negotiated the kind of services she would need. Janet is happy with the result of her surgery, and is now getting on with her life. 

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