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Patient Focused Changes in New Proposed Affordable Care Act Regulations

Posted by andreahgreif in The LLS Blog, 22 December 2014 · 72 views
health care reform, ACA and 3 more...

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The second year of the Affordable Care Act is well under way: the health insurance marketplaces opened for re-enrollment on November 15 and will continue to accept enrollees through February 15. But federal healthcare officials who oversee the administration of the healthcare law – the officials at the Centers of Medicare and Medicaid Services (CMS) of the Department of Health and Human Services (HHS) - are already looking to 2016 and identifying ways to make the law better for patients next year.

Our policy and advocacy team here at The Leukemia & Lymphoma Society has been active and vocal for the past two years in expressing concerns we have had with aspects of some insurance plans included in these marketplaces. While health care reform clearly brought benefits to patients– ensuring access to care for more patients, and no longer blocking access to care for people with pre-existing conditions, for example – we have pointed to several issues that impede access for patients.

This week CMS unveiled its proposed rule for the 2016 “essential health benefits” – those regulations that all plans in the marketplaces must adhere to. It appears that CMS has been listening to us at LLS. If these rules are adopted as final, as we expect, it will be a win for the blood cancer patients we serve.

• Transparency regarding which drugs a plan includes. We have found that patients have had a hard time finding out if their therapies are covered under the insurance plans they select in the marketplaces. Some insurance plans simply do not clearly list what is included on their formularies – the official list of drugs they cover. CMS is now requiring that for 2016 insurers post their formularies on their public website — where they could be accessed without a consumer creating or accessing an account or entering a policy number — clearly identifying which formulary goes with which plan. The information should be up-to-date and accurate and should be linked from the plan’s summary of benefits and coverage.

• Network adequacy. As with the drug formularies, some insurance plans make it difficult to know if your doctor or medical group is included in their networks. CMS proposes that a qualified health plan issuer be required to publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, as well as providers’ location, contact information, specialty, medical group, and any institutional affiliations. The insurer must update the directory information at least monthly, and must permit the public to view all of the current providers for a plan on the plan’s public website through a clearly identifiable link without having to create or access an account or enter a policy number.

• Out of pocket cost limits for drugs. Patients have run into situations where their costs for therapies were not being applied to their out-of-pocket limits – the maximum amount that a patients would be expected to pay during a policy period before your health insurance pays 100% for covered essential health benefits. For example, one important change in the proposed rule would add a “standard exceptions process,” so that a patient or physician could request coverage of an off-formulary product and receive an answer within 72 hours in non-emergency circumstances. Any drug covered through this exceptions process would be considered an essential health benefit and the patient’s cost-sharing would count against the out-of-pocket limit.

• Steps to address discriminatory benefit design. CMS has not proposed a new rule to address discriminatory practices by insurance companies; it does address the issue in its preface. Patient advocacy organizations such as LLS have raised red flags that some plans appear to discourage enrollment based on age or health conditions even though this is prohibited. An insurer that puts most or all drugs that treat a specific condition on the highest cost tiers effectively discriminates against individuals with that condition. CMS will be more closely monitoring these types of practices to ensure compliance with the non-discrimination requirements in the Affordable Care Act.



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