Stronger Patient Protections Are Around the Corner

While overuse of costly services benefits no one, policymakers should ban cost-sharing arrangements that impede appropriate health seeking behaviors, especially for people with chronic conditions.
12/18/2014 03:16 pm ET Updated Feb 17, 2015

Since the federal health insurance exchange opened in November for people to enroll in 2015 plans, nearly 1 million Americans have signed up for coverage.

One of the most laudable goals of the Affordable Care Act is to end discrimination against people with chronic diseases and disabilities that has long plagued our health care system. However, many of the health plans sold through the exchanges continue to discriminate by providing inadequate information about coverage and imposing serious barriers to care.

The Centers for Medicare and Medicaid Services has proposed a new rule that will toughen the standards for health plans sold through the insurance marketplace. This rule would make health plan information more transparent, improve access to needed medications, and reduce barriers to accessing health care. It's a good start, but regulators need to strengthen their proposal.

When people shop for health plans in the exchange they are frequently frustrated by the lack of easy-to-find and easy-to-use information. It is often difficult to access details about which medications are covered and whether a preferred doctor or hospital is in-network.

Under the proposed rule, insurance companies would have to make such critical information more transparent. The companies would be required to create websites to easily share up-to-date provider network details and a complete, accurate drug formulary.

This is a smart move. CMS is also considering going one step further by requiring the use of a standard template for provider networks and formularies, including requiring that the template be in a machine-readable format to ease creation of consumer tools. This uniform formatting will make it possible for people to compare details across the growing number of health plans being sold through the exchanges.

Another obstacle enrollees currently face is accessing affordable medications. Insurance providers often design a plan's drug formulary so that specialty prescription drugs used by people with complex health conditions fall into the highest cost-sharing level. Notably, in the 2015 exchange market there is an increased incidence of plans charging coinsurance greater than 30 percent for specialty medications when compared to the 2014 plan year. Specifically, the use of coinsurance greater than 30 percent has increased from 27 percent of Silver plans in 2014 to 41 percent in 2015.

The proposed rule encourages states to update their guidelines for determining whether exchange plans offer adequate, affordable coverage, and it requires the Department of Health and Human Services to review these changes.

The new rule also would prohibit insurers from changing their formularies mid-year -- a practice that too often deprives people with chronic conditions of the drug coverage they selected when they first signed up for an insurance plan.

Finally, the CMS proposed rule addresses the barriers patients come up against when switching health plans. People with chronic conditions face both health quality and cost consequences when they are unable to continue their treatment routine while they scramble to find a provider covered by a new plan or to get a prior prescription refilled.

For these patients, the proposed rule provides for "transition care" by suggesting that new insurers cover access to the patient's providers for the first 30 days under the new plan and a one-month supply of medications regardless of whether the drugs are on the plan's formulary. Regulators should make this protection a requirement, not merely a suggestion, and consider covering 90 days' worth of transition refills.

While overuse of costly services benefits no one, policymakers should ban cost-sharing arrangements that impede appropriate health seeking behaviors, especially for people with chronic conditions.

In proposing these and other important changes to the insurance marketplace, the Administration has shown its commitment to the principle of non-discrimination, which is at the heart of the Affordable Care Act. Finalizing the new rule would be an important step toward a health care system in which people with chronic conditions no longer have to sacrifice their well-being to avoid high health care costs.