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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.

End scenario.

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.

Average: 5 (1 vote)


Submitted by Dromaius on

Note, for those visiting from other blogs who say, “well there may be alternative places to get that coverage” (You know who you are). The Blue Cross/Blue Shield affiliate that offers Exchange plans in my area (Premera) also does not have in-network ANY of the research/teaching cancer or trauma centers in the area so other cutting edge cancer treatments are also limited.

The other main plan (Bridgespan) DOES offer some of the research hospitals but does not have a national or even state-wide contracted provider system (see my attached jpg). Thus if you might get cancer, you can sign up for possible cutting edge treatment (Bridgespan) or you can have travel with guaranteed coverage and get no cutting edge treatment (Premera).

So we have choices at least. LOL

File attachments: 

jo6pac's picture
Submitted by jo6pac on

the Hurry Up & Die health insurance plan. We don't want any long term sick people, old people, and anyone over 55 off to Medicaid you go. Thanks for your time.

Alexa's picture
Submitted by Alexa on

especially in regard to "children's networks."

For all the hatefulness that some Republicans spewed about providing healthcare for all, they were correct about one thing--costs would just be "shifted."

This is why I hope that Mr A will be able to explain the details of underwriting (which is partly an actuarial science).

Everyone in the insurance industry knew this would be the case. The insurance companies NEVER absorb losses. (That's rule number one!)

Too bad that Dems and Repubs sold us out to the insurance companies.

Now that this has happened, though, I can't imagine that it can be reversed. ;-(

Splashoil's picture
Submitted by Splashoil on

I just called Olympia. Kriedler's spokesman said his office had opposed several scant plans but they were overruled by Jay Inslee's appointed insurance commissioners. So another call to the Governor will be needed.
Thank you for bringing this out!

Submitted by Dromaius on

I suspect they're talking about "Coordinated Care" and Molina. These were two plans that they rejected and then later were reinstated. Those firms are not as powerful in the state, so I suspect they figured they could tactically throw them under the bus.

My posts focus on Premera and Bridgespan, which come from the most powerful insurance co's in the state. They should have been rejected for similar reasons as the others, such as lack of coverage for children, but were given a pass.

The Governor and the Insurance Commissioner both have people trained to give you the runaround, and that's what they appear to be doing to you.

My tactic is to try and get the newspapers and other media to cover the problems so that people can at least be informed. Of course, they also have some complex "marriages".

Rainbow Girl's picture
Submitted by Rainbow Girl on

I'm sure the meetings and correspondence where Inslee and the Insurance Commissioners and the other "stakeholders" (the unterbussens) are totally public and there are easily available transcripts of all proceedings, etc. etc.

Yeah right. Wouldn't it be interesting though, if such things were mandated to be conducted in public?

Meanwhile, back in reality -- Splashoil, please report back on any interaction with Governor's office!

Splashoil's picture
Submitted by Splashoil on

The Governor's office was very polite, but merely took my call with no response. Did not even take my contact information. I slugged out all the points and did not take hostages. WA residents please call Gov. Jay Inslee 360-902-4111. There is also an email form on the website.

Submitted by Dromaius on

Whatever you do, don't let them fool you into thinking that "Coordinated Care" and "Molina" are the problem.

The Big 2, Bridgespan(Regence/Cambria) and Premera are what I'm talking about. They are the ones that Children's is ultimately suing about, even though they're asking to have Molina and CC removed from the plan selection.

Submitted by Dromaius on

Also, this is not a Washington-specific problem.

The thin plans were purposely created to come in at "lower than expected" prices and give the illusion of insurance. They, and their huge down sides are a NATIONWIDE problem.

I use Washington as my case study, because I know Washington and because it's facility for finding doctors and plans etc. seems to be unusually stable compared to the rest of the country.

But this is










just a local problem.

Submitted by Dromaius on

Because I believe the release of these skinny plans was purposeful for the reasons I gave above, I don't believe contacting the governor or the insurance commissioner to "alert them" about things is going to help.

What WILL help is to inform consumers about them so they can navigate the pitfalls.

Rainbow Girl's picture
Submitted by Rainbow Girl on

One cannot browse plans (or comparison shop, or figure out what's covered or how anorexic the networks are) without first handing over every piece of personal data you can imagine, including SS#. At least as of today, you cannot simply create an account with a name and email address and then go window-shopping.

Stage one of account creation is benign -- name, email address and user id. But then you have to receive an email back with a link to click on to "finish the registration process" (paraphrase). Then, the heavy questions come. And that page opens with a blue banner basically saying that every action done by you (with your user id in their system by now) is being watched and monitored. There are reminders of criminal penalties for "unlawful use of information" in the website though what those unlawful uses are is not explained.

I wonder if Rall had to provide all that info before getting in to the actual plan section.

In any event, this is to put it mildly, creepy.