Newly insured consumers in Washington state who purchased health plans through the online exchange might find a surprise when they comb through the fine print in their policies: They’ll have to wait 90 days from when their insurance begins before coverage for transplants will kick in.
The waiting period, a holdover from the days when insurers were able to impose restrictions on coverage for all sorts of preexisting conditions, has become the latest flash point in the often tense negotiations between insurers, regulators, doctors and consumers over the design of the new individual and small-group health plans that went into effect Jan 1.
Specialists who treat patients with cancer, heart disease and other chronic illnesses are outraged by the requirement and say there is no medical basis for it. They accuse insurers of violating Affordable Care Act provisions that prohibit discrimination against those with specific diseases.
The waiting-period rule, which is in effect for policies sold by Premera Blue Cross, BridgeSpan Health, Moda Health and Group Health, applies to the entire transplant process, meaning that patients must wait 90 days before even beginning an evaluation. The evaluations, which include everything from screening tests to interviews with social workers and nutritionists, often take several months. Once a patient is approved, the wait on a transplant list could be several more months or even years, depending on the person’s condition, the organ involved, and the hospital.
“The whole idea of creating a waiting period for someone who is dying of organ failure is the antithesis of what the Affordable Care Act is supposed to be about,” said Roslyn B. Mannon, immediate past president of the American Society of Transplantation and a transplant nephrologist at the University of Alabama at Birmingham.
Susanna Nazarian, assistant professor of transplant surgery at the University of Washington, put it more bluntly: “Putting this additional barrier in front of them will lead to some patients passing away.”
Insurance company representatives said they were complying with what is allowed under the Washington state benchmark plan. Stephanie Marquis, a spokeswoman for the Washington state insurance commissioner’s office, said the original waiting period for transplants for plans purchased through the state exchange was six months but it was reduced to 90 days “to match what was allowed under federal law.”
Marquis said the insurance office has since heard from consumers who think that any waiting period is discriminatory, and that the office is looking into the issue further.
“I can’t give you a specific time frame yet, but we do take their concerns seriously,” she said.
The waiting periods apply only to those who did not have prior coverage. If a member had been continuously enrolled in a different plan 90 days prior to incurring the transplant-related expenses, he or she would be exempt. If a member had coverage for less than 90 days, the exclusion period is reduced by one day for each day of prior coverage.
Patient advocates have successfully pushed back against a similar provision in Oregon that allowed insurers to impose a 24-month waiting period for transplants. The insurance commissioner eliminated that rule on Dec. 31 and told insurers there should be no waiting period.
Sandy Praeger, past president of the National Association of Insurance Commissioners and the head of the insurance department in Kansas, said she has not heard about similar restrictions on transplants in other states, but she expects more issues to arise in the coming year as consumers who purchased the plans start to visit doctors. “It’s something that might not surface until people start exercising their benefits. They may not realize the waiting period was in there,” she said.
The Affordable Care Act prohibits “excessive” waiting periods, which it defines as more than 90 days. But it does not indicate whether specific benefits could be subject to a waiting period, and state officials have interpreted the law in different ways.