New health insurance options and protections for people with pre-existing health conditions included in the Affordable Care Act (ACA) are now fully in place.  However, there were still many unanswered questions and uncertainties about specific regulations and requirements for insurance companies who decide to offer health plans in the new Health Insurance Marketplaces.  Since the passage of the ACA in 2010 the National Kidney Foundation has been advocating for answers to these questions.  Thankfully, on May 16, 2014, the Centers for Medicare & Medicaid Services (CMS) publicly released a final rule and a frequently asked questions (FAQ) document that provided some clarity for people with kidney disease. 

1. Plans may not terminate coverage based on someone’s Medicare eligibility.  This means if you are enrolled in an individual qualified health plan (QHP) and later require dialysis or a kidney transplant, your insurance company may not end your coverage without your consent. The company must renew your coverage if you want to say enrolled, even if you also decide to enroll in Medicare.  However, the law does not require your health plan to pay the Medicare coinsurance, which is typically 20% for dialysis and other outpatient doctor’s visits.  Also, if you choose to enroll in Medicare, the amount you pay for your QHP premiums may go up because you will no longer qualify for tax credits or subsidies.  While existing law already stated that insurers could not terminate coverage based on Medicare eligibility, some insurers were unaware or interpreted the law differently. This clarification from CMS is expected to end this practice by all insurers.
2. The FAQ document specifically states that health plans may not impose waiting periods on benefits like coverage for transplantation.  Last year, Oregon had a proposal to permit insurers to institute waiting periods, and fortunately the state decided not to move forward with that proposal.  However, Washington State did permit a 90 day waiting period and some insurers adopted it, but now the Federal government clarified that no waiting period is allowed. We therefore expect the state of Washington to overturn their policy and that no other states will allow it in the future.
3. QHPs must make decisions within 24 hours on appeals for covering drugs for any person suffering from a health condition that may seriously jeopardize their life, health, or ability to regain maximum function. This also applies when a patient is undergoing a current course of treatment using a medication that is not on the plan’s drug formulary (e.g., a drug that is not routinely covered by the plan).  This requirement applies to combinations of medications like immunosuppressives.

If you have a QHP and have questions about your coverage, you should speak to your social worker or contact NKF CARES at 1.855.NKF.CARES (1.855.653.2273) or email nkfcares@kidney.org.

Here are links to both policy documents in case you need them as resources or simply enjoy reading complex Medicare regulations!

FAQ:  http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Final-Master-FAQs-5-16-14.pdf.

Final regulation:  http://ofr.gov/OFRUpload/OFRData/2014-11657_PI.pdf