FEATURE
What You Don’t Know About the ACA
SIDEBAR
Essential Health
Benefits
All private health insurance
plans offered in the marketplace offer the same set of
essential health benefits,
which must include:
• Ambulatory patient services
• Emergency services
• Hospitalization
• Pregnancy, maternity, and
newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services and devices
is in-network before signing up for a specific plan or going to visit their doctors,”
Ms. Silver advised.
In some cases, health insurance companies will make exemptions and patients
can try to advocate for coverage if they
have a chronic illness, she added. “This is
especially applicable for someone with a
blood cancer who can show that they have
been in the care of a specific physician for
a long period of time,” Ms. Silver said.
Out-of-Pocket Versus In-Pocket
The out-of-pocket maximum limits set
at $6,600 and $13,200 per year are great
TABLE.
have purchased at least a silver-level plan
through the marketplace may also qualify
for financial assistance through cost-sharing subsidies, which reduce their out-ofpocket limit.
For example, with a cost-sharing
reduction, a person at 100 to 150 percent
of the federal poverty level would have
an adjusted out-of-pocket maximum of
$2,250 for an individual and $4,500 for a
family (TABLE).4
Both of these cost-saving elements,
however, are only available to people who
purchase their coverage through marketplace exchanges.
Maximum Annual Limitation on Cost Sharing
Income (% of Federal
Poverty Level)
Reduced Maximum Annual Reduced Maximum Annual
Limit of Cost-Sharing for
Limit of Cost-Sharing for
Individual (2015)
Family (2015)
100% to 150%
$2,250
$4,500
150% to 200%
$2,250
$4,500
200% to 250%
$5,200
$10,400
Over 250%
$6,600
$13,200
• Laboratory services
• Preventive and wellness
services and chronic disease
management
• Pediatric services
For patients needing additional
financial assistance in covering
the drug costs associated with
their hematologic condition,
ASH offers information on
high-cost hematologic drug
access programs through its
website at www.hematology.org/Clinicians/Drugs/
Programs. Here, patients can
find access programs funded
by drug manufacturers or
private foundations for many
of the commonly used drugs
for hematologic conditions. In
addition, template letters are
also available for physicians
who wish to file an appeal with
health insurance companies
to allow coverage of the use
of specialty-tier drugs for their
patients.
Recently, ASH has helped
to introduce legislation that
would decrease the burden
of excessive cost-sharing for
people who need high-cost,
specialty-tier medications.
Currently, patients are required
to pay a percentage of the cost
of these drugs, anywhere from
25 percent to 33 percent or
higher. The recently introduced
Patients’ Access to Treatments
Act would instead require
patients to pay a much lower,
fixed co-payment.5
46
ASH Clinical News
Source: “Patient Protection and Affordable Care Act; HHS Notice of Benefit of Payment Parameters for 2015,” Federal Register 79, no. 47 (March
11, 2014): 13744.
news – for those who can afford them.
But how do low-income individuals and
families handle expenses that dig too deep
into their pockets?
If they meet certain income qualifications, people with lower household
incomes who are not eligible for Medicare,
Medicaid, the Children’s Health Insurance Program, or other forms of public
assistance can qualify for a premium
tax credit that sets a cap on the amount
a person or family must spend on their
monthly health insurance payments. In
addition, people with low incomes who
“Arming patients
with information will go a
long way to
helping them
understand their
potential out-ofpocket costs.”
—PETER SHIN, MD, MPH
What Can Physicians Do?
Presumably, like many physicians, Kenneth Adler, MD, a hematologist/oncologist
with Regional Cancer Care Associates in
Morristown, New Jersey, admits that when
seeing patients with chronic hematologic
conditions or malignancies, his time is
prioritized for discussing patient care, concerns, and treatment options – not necessaril