Obamacare Exchange: Loopholes to skirt requirements, cancer treatment edition
The American Society has a full-color brochure about how great Obamacare is for cancer patients.
The myth (from the brochure)
Taylor Wilhite of Marblehead, Ohio, was diagnosed with acute myeloid leukemia in 2007 at the age of 8. She received three rounds of chemotherapy, had a bone marrow transplant, and at one point was taking 23 pills a day along with many IV medicines. Now age 12, Taylor is in remission. But the costs of her treatment quickly reached her insurance plan’s lifetime benefits cap, leaving her family struggling to pay for the care she needed for the side effects of her treatment.
The Affordable Care Act does not allow health plans to place lifetime caps on coverage. The law restricts and soon will ban yearly limits. This will give people like Taylor and her family peace of mind that coverage will not suddenly end because of caps on benefits.
The Reality Scenario:
Yes! Affordable Care Act removes lifetime caps so my child can have their lifesaving bone marrow transplant! Yayyyyyy.
Okay, here’s the national registry for locating bone marrow transplant centers. Let’s look them up and go see ‘em and save my baby’s life!
Okay! So for my Washington state, the transplant centers are Seattle Cancer Care Alliance (SCCA) and VA Puget Sound Health Care System.
Okay! Well, I’ve signed up for a Blue Cross/Blue Shield plan on the Exchange. BCBS brags of having the largest provider network in the country. And WOW, SCCA is local so we don’t even have to travel!
Oh, SCCA is not on my provider list, and nor is the VA Hospital? Gee, did I choose the wrong insurance? Well, it’s open enrollment time. I can change. What? None of the insurance companies on my state Exchange have SCCA or VA Hospital in their provider list?
OMFG!!!!! Well, I guess we’d better not cancel those bake sales and grocery store money collection jars after all.
The Shell Game
When Liz Fowler wrote the Affordable Care Act, she oopsied (oh, darn it, Liz!) and forgot to include treatment for critically ill patients in its list of “essential benefits,” even when Transplant advocates lobbied for its inclusion. In addition, she wrote no restrictions on inclusion of providers in insurers’ networks. Thus, while insurance can no longer have lifetime caps, it can and does eliminate treatment centers for illnesses that historically resulted in reaching those caps. Good loophole, Liz! You definitely earned that bonus you likely received when you returned to private industry.
I have a post in the works on how disclusion of providers in plan networks appears to target specific markets and treatments, using my state as a case study. Look for it soon (first rainy day ;-) )
As a fun exercise, look up the transplant centers in your state (there will only be a few) and see if any of them are covered under any plans on your Exchange. Please post any findings in the comments.