Provisions of the Affordable Care Act (ACA) will likely have broad-sweeping implications for the Parkinson’s community. PAN is taking action with the goal of ensuring the voices and concerns of our community are represented as decisions are made by providing comments when appropriate.
On July 28, 2014, PAN joined with over 300 patient groups in a letter to Health and Human Services Secretary Sylvia Burwell asking her to address issues that people with chronic conditions have encountered in the first year of coverage in the new Health Insurance Exchanges under the ACA. Specifically, the letter urges Burwell to enforce the ACA’s non-discrimination provisions that eliminate coverage and cost barriers for people with pre-existing conditions, find solutions to high cost-sharing and insufficient provider networks in some areas, and increase insurance plan transparency for all consumers.
Issues and Resources
Here is a quick run-down of the main issues PAN is monitoring. We will update as new information becomes available.
Health Insurance Exchanges
Beginning January 1, 2014, state-based Health Insurance Exchanges and Small Business Health Option Program (SHOP) exchanges will begin operations nationwide. States that opt not to develop an exchange program will have one administered directly by the federal government. The exchanges will allow individuals and small businesses with up to 100 employees to purchase qualified health insurance coverage. Open enrollment for the exchanges will begin October 1, 2013 and run through March 31, 2014.
Essential Health Benefits
The ACA requires health plans for individuals who are uninsured or who will be insured through an individual or small group policy to offer, beginning in 2014, a comprehensive package of Essential Health Benefits (EHB). EHB must include items and services within at least 10 categories, such as prescription drugs and hospitalizations.
Since January 2012, PAN has submitted comments in response to bulletins and proposed rules issued by the Department of Health and Human Services (HHS) for EHB, expressing concerns related to access to prescription drugs and cost-sharing.
- PAN Summary of EHB concerns
- PAN Response to HHS EHB Bulletin (January 2012)
- PAN Comments on Data Collection – Prescription drugs; treatment limitations; cost-sharing (July 2012)
- PAN Sign-on letter to HHS Sec. Sebelius – Prescription drugs; cost-sharing (October 2012)
- PAN Comments on EHB Proposed Final Rule – Prescription drugs; benefit design flexibility; cost-sharing; medical necessity appeals (December 2012)
HHS released the final rule for EHB on February 20, 2013. PAN is pleased that HHS modified the final rule to require health plans to have a process to gain access to medically necessary prescription drugs that may not be part of the plan’s formulary. However, we still have two primary concerns with the EHB provision for prescription drugs:
- Because individual states are allowed to design their own prescription coverage plans that meet EHB standards, the number of drugs that can be accessed by patients may vary widely from state to state. One state’s plan may elect to cover as many as 500 different drugs while another’s may cover over 1000.
- HHS has not yet proposed a process to ensure that innovative new drugs, while generally accepted, are formally recognized in plan coverage as quickly as possible. In the interim, this could potentially lead to patients being denied critical health management and life-saving therapies.
Out of Pocket Expenses
PAN joined with over 100 patient advocate and health care organizations on April 16, 2013 in signing a letter urging the Administration to change its policy on out-of-pocket costs that people with chronic conditions will be charged starting in 2014.