FEATURE
What You Don’t Know About the ACA
May Hurt Your Patients!
The ACA Out-of-Pocket Limit:
Good and Bad News for Hematology Patients
Although the act sets limits on the out-of-pocket expenses a patient might face, many costs associated with
hematologic care may fall outside of the limit.
It is a truth universally acknowledged: paying
for medical care presents a financial hardship
for many Americans. As physicians in the
hematology and oncology arena know, patients
with chronic hematologic conditions will
likely face even greater financial costs. Less
well-known though, is a measure of the Patient
Protection and Affordable Care Act (ACA)
designed to lighten the financial burden of
treating these chronic conditions: the institution of an out-of-pocket maximum or limit.
According to HealthCare.gov, the out-ofpocket limit is the most that individual enrollees have to pay during a policy period before
their health insurance coverage plan starts to
pay 100 percent for covered essential health
benefits (see SIDEBAR).1
For 2015, the maximum-out-of-pocket
limits are $6,600 for an individual plan and
$13,200 for a family plan. This limit must include deductibles, coinsurance, copayments, or
similar charges, and any other qualified medical expense for those essential health benefits.
“In the past, your coverage plan might
have had an out-of-pocket maximum, but it
was not required to,” Johanna Gray, MPA,
vice president of Cavarocchi, Ruscio, Dennis
Associates, a government relations, public
policy, and strategic development firm that
works with the Society, told ASH Clinical
News.
It is important for patients to know what is
and is not included in the out-of-pocket limit,
she added. “That $6,600 and $13,200 limit only
applies to essential health benefits, and does
not include monthly premiums, balance billing
amounts for non-network providers and other
out-of-network cost-sharing, or money spent
on drugs that are not covered or non-essential
health benefits.”
The out-of-pocket limit protections began
in January 2014, but many large health insurance companies were not required to include
these maximums until January 1, 2015. Grandfathered plans, or those in existence prior to
the ACA being signed into law in 2010, do not
have to comply at all.
In addition, some employer-provided plans
may set out-of-pocket maximums below these
levels; these lower limits, however, may not
include the prescription drug plan, which can
have its own maximum limit. This is allowed
as long as the two out-of-pocket maximums do
not exceed the maximum out-of-pocket limits
set forth by the government.
ASHClinicalNews.org
Are Narrowing Networks
Squeezing out Hematologic Care?
The out-of-pocket limits that were implemented this year may help to keep health-care
costs manageable for many individuals, but, for
patients with chronic conditions, the costs can
still pile up.
“Anyone with a chronic hematologic condition will likely reach their out-of-pocket maximum fairly quickly, simply due to the number
of office visits and prescription drugs involved
in treating these conditions,” said Alicia Silver,
MPP, a health policy analyst specializing in
payer policy and legislative relations at the National Marrow Donor Program/Be The Match.
For example, the main treatment for
hemophilia and other bleeding disorders is an
expensive clotting factor replacement therapy;
some patients undergo infusions with clotting
factors on a regular basis to prevent bleeding.
The costs of those frequent treatments add
up, Ms. Gray explained. “The average cost for
severe hemophilia – just for medication – is
about $300,000 per year. Depending on what
insurance covers, a patient may need to pay 10
percent of each month’s prescription costs or
even more,” she said. In other words, a person
may have to put out their entire out-of-pocket
maximum, up to $6,600, within the first few
months of the year.
Patients with chronic hematologic conditions face other challenges, as well. As mentioned earlier, copays and coinsurance costs
are only applied to the maximum $6,600 limit
if they are considered to be in-network costs.
And, while the ACA set minimum standard
requirements for health insurance plans, the
required composition of providers offered
within each network was not mandated. That
can cause big problems for patients with hematologic malignancies.
One examination of policies sold on
insurance exchanges in California, New York,
Florida, and Texas found that coverage varied
widely for people with hematologic malignancies – specifically, those who might need any of
the three most commonly used drugs to treat
chronic myeloid leukemia (imatinib, nilotinib,
and dasatinib) or the five most commonly used
drugs for multiple myeloma (thalidomide,
lenalidomide, pomalidomide, cyclophosphamide, and melphalan).2 [