Whether you're deciding which type of coverage is most appropriate or whether you're in the middle of the plan year and have concerns about your coverage, providing feedback to The Leukemia & Lymphoma Society and to state and federal health officials is very important.
Governments at both the state and federal levels will be looking for ongoing consumer complaints, questions and feedback. Consumer feedback is absolutely essential to improving the law because implementation and improvements will continue for years.
LLS will continue to be a resource to patients and their families through our Information Resource Center (IRC) as well as local patient support staff. You can reach our information resource center by calling 1-800-955-4572, Monday to Friday, 9 a.m. to 6 p.m. ET.
Provider networks are set by insurance companies. All insurance marketplaces are required to provide a list of in-network providers to consumers. It is important to double check with both the insurance company plan and your provider to confirm that your provider is covered under the network of the plan you choose.
If you sign up for a plan and find out later that your provider is not covered as promised, you can speak with an information specialist at our Information Resource Center (IRC) for additional support at: 1 (800) 955-4572. You can also contact the insurance commission in your state for further assistance. Find your insurance commission here: www.naic.org/state_web_map.
Many insurance plans within the insurance marketplace may not cover National Cancer Institute designated cancer treatment centers. When you are looking for coverage through your state or federal insurance marketplace, there is a required website link that will take you to that insurance company's website where you can find a listing of providers, hospitals and cancer centers. The web link on the site may be titled "Network Coverage" or "Provider Directory."
We encourage anyone looking for coverage to contact the insurance plan provider directly as well as the cancer treatment center to ensure that the insurance plan you chose includes your treatment center in their network and what the visit would cost you.
Beginning January 1, 2014, health plans in the small group and individual markets must comply with a total annual out of pocket (OOP) maximum of $6,350 for in-network expenses for an individual and $12,700 for a family. This means your total OOP or payment for healthcare services is limited to these amounts annually. However, cancer patients should be mindful that only in-network services and treatments count toward the annual OOP maximum. Also, your OOP maximum does not include your monthly premium.. It is imperative for a patient to check with their plan to ensure if their drugs are covered and if their physician, hospital and specialty cancer center is in-network, or they risk paying higher costs.
State parity laws are pieces of legislation that require insurance companies to have parity in cost-sharing between intravenous and oral forms of cancer treatment. These laws, already in existence, are not impacted by the ACA - the individual and small group markets must follow the guidelines of their state's law to create parity for patients.
For states without parity, the ACA does not address the challenge of patients faced with thousands of dollars in prescription drug costs each month. Beginning January 1, 2014, health plans in the small group and individual market must comply with a total annual out-of-pocket maximum of $6,350 for in-network expenses. However, this does not protect patients from high deductibles and high co-insurances for drugs or services in their health plan. LLS continues to advocate for changes in the insurance market that would give patients broader, more affordable access to the treatment they need.
No. These rules - usually referred to as "utilization management" - are not specifically addressed in the ACA. Generally, this means insurers can continue applying these rules however they see fit, except in states that have passed their own laws addressing utilization management techniques. For example, some states have a law requiring insurers to respond within 72 hours to a request for prior authorization. Insurers operating in those states would have to abide by that timeframe, even though it's not specified in the ACA.
The ACA was designed to phase out the coverage gap found in most Medicare drug plans. Usually called the "donut hole," this gap refers to instances where Medicare enrollees - after having spent a certain amount of money on their prescription drugs - would become temporarily responsible for covering an increased share of their drug costs. Under the ACA, this gap will be phased out gradually between now and 2020. This is an important change for blood cancer patients on Medicare whose treatment involves high-cost drugs. Click here to visit the Medicare website where you can learn more about the impact to your specific type of plan.
To be considered "grandfathered," a health insurance plan must have been in existence prior to the ACA being signed into law on March 23, 2010. To retain that status moving forward, a grandfathered plan cannot be changed in certain ways: consumers may not be forced to take on a larger share of their health care costs, and covered benefits may not be cut.
Grandfathered health plans do not have to comply with certain patient protections included in the ACA. For example, the ACA requires insurers to cover 100% of the cost of certain preventive services but grandfathered health plans are not subject to this requirement. Some grandfathered plans do not have to cover pre-existing conditions.
There are two types of grandfathered plans: group plans sponsored by an employer and individual plans. The second kind refers to plans you buy on your own, as an individual. The ACA allowed the first kind - grandfathered plans that are job-based - to continue enrolling people after March 23, 2010 and still be considered a grandfathered plan. So, if your health insurance is provided through your employer, you may want to ask your employer or your insurance company if your plan is grandfathered, even if you enrolled after March 23, 2010. Having this information will help you better understand what benefits the ACA requires your plan to cover.