Insurance Exchanges Limit Access for Patients With Blood Cancer

Roxanne Nelson

February 19, 2014

Although the Patient Protection and Affordable Care Act (ACA) will make it easier for patients with leukemia and lymphoma to obtain health insurance, it could inadvertently limit their access to care.

According to a new report commissioned by the Leukemia & Lymphoma Society (LLS), a number of the health plans that are participating in the insurance exchanges offer limited access to National Cancer Institute (NCI)-designated cancer or transplant centers. This will substantially raise out-of-pocket costs for patients.

"Qualified health plans are sporadic at best and ineffective in covering NCI transplant and cancer centers," said Brian Rosen, JD, senior vice president of public policy at the LLS. "For example, in New York, we looked at major insurers in the exchanges and found that Memorial Sloan-Kettering was not covered by many of them."

The report, prepared by Milliman, Inc., gives an early evaluation of 2014 individual benefit designs, coverage, and premiums for policies sold on insurance exchanges in 4 large and diverse states: California, Florida, New York, and Texas.

Specifically, it looks at how these plans will affect coverage for patients with hematologic cancers, such as whether cancer centers and transplant centers designated by the NCI are included as "in-network" facilities.

NCI-designated facilities were also being left out of in-network coverage by major insurers in California, Florida, and Texas. "These narrow networks are problematic for our patients."

Although there are no real data yet on how patients are being affected because the program is still very new, anecdotally, the LLS is already hearing stories about how access is being limited, Rosen explained.

High Deductibles

The ACA mandated the creation of exchanges where individuals can purchase healthcare insurance and where people meeting certain criteria will be eligible for government subsidies. Some of the exchanges are operated by individual states, whereas others are operated completely or partially by the federal government.

The qualified health plans on the exchanges must meet standard benefit designs, which are categorized as platinum (most expensive), gold, silver, and bronze (least expensive). There is variation among the exchange plans, primarily in the deductible and premium rates.

Plans vary from state to state, and the report even found "significant variation" in premium rates within particular cities. The bronze and silver plans offer the lowest monthly premiums but higher deductibles, requiring significant cost-sharing for patients. The data reveal that these lower-tier plans come with high deductibles, which are sometimes nearly as high as the out-of-pocket ceiling. In this 4-state survey, deductibles for the silver plans for individuals were at least $2000 and for the bronze plans were at least $4000.

Out-of-Network Facilities Boosts Cost

However, the maximum out-of-pocket limits set for 2014 are $6350 for an individual policy and $12,799 for a family policy. Some insurers are offering plans with lower out-of-pocket limits, but they do not apply when a patient goes out of network to obtain care.

The out-of-network limits are set at higher levels, but most plans on these exchanges offer no coverage for out-of-network providers, according to the survey. Therefore, it is unlikely that any out-of-network expenses will count toward a patient's out-of-pocket maximum, and patients can easily incur thousands of dollars of medical expenses and never reach their out-of-pocket maximum.

The data show that many specialty providers and centers caring for patients with hematologic cancers have been excluded from the health insurance exchange plans. "I imagine that this is all about cost, that insurers are attempting to save dollars where they can and they have to narrow their networks," he added.

The LLS is trying to educate patients about the exchange and provide them with information. "We are trying to provide information to patients, but we can't reach everyone," Rosen said. "Those who contact us or visit our network will receive help in getting the right answers, especially about purchasing at the silver and bronze levels."


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