Principles for Meaningful Coverage

To access the care they need, cancer patients must have access to meaningful health insurance coverage. Their lives quite literally depend on it. But what qualifies as ‘meaningful’? It’s critical that the patient advocacy community clearly define this term and its component parts, so that together we’re able to effectively protect and promote the interests of people and families living with cancer. To that end, The Leukemia & Lymphoma Society (LLS) offers the following Coverage Principles, broadly describing the characteristics of meaningful coverage. Each principle is further defined by a set of public policies. LLS believes that these policies must be enshrined in the laws and rules that underpin our healthcare ecosystem, in order for patients to have the practical benefit of ‘meaningful’ coverage.

Guarantee Access: Cancer patients rely on insurance to help cover the cost of the often-costly treatments that can mean the difference between life and death. Cancer patients must continue to have the right to purchase quality, affordable health insurance to help them access the care they need. The following policies are essential to guaranteeing access to coverage:

• Guaranteed Availability of Coverage[i] – Insurers must accept any consumer willing to purchase their insurance products, using the same rules for all consumers to prevent discrimination against consumers with a diagnosis like cancer.
• Guarantee of Coverage for Preexisting Conditions[ii] – Insurers must cover all eligible healthcare services incurred by their covered patients, regardless of whether the patient had a health condition before purchasing coverage.
• Prohibition on Rescissions[iii] – Cancer patients should have the peace of mind that their insurer cannot strip away their coverage or benefits when they need it most.
• Prohibition on Lifetime Maximums[iv] – Cancer patients do not have real insurance access if insurers can subject them to a cap that effectively renders patients without coverage after a certain amount of spending by the insurer.

Ensure Quality: Cancer patients need insurance coverage that will help them access lifesaving care when they need it. While the existing rules governing the quality of coverage need improving, cancer patients currently have the peace of mind that every insurance plan option will cover minimum benefits and sufficient providers to access cancer treatments and drugs. Policymakers must continue to provide minimum standards for quality that protect patients from being locked out of necessary treatment due to barebones coverage. The following policies are essential to encouraging quality of coverage:

• Prohibition on Discriminatory Benefit Plans[v] – Consistent with the guarantee of coverage for all consumers, regardless of health status, insurers should not be permitted to design benefits that discourage enrollment by certain high-cost individuals. Plans that disproportionately limit coverage of treatments for serious illnesses or that expose these patients to extraordinarily high costs should not be permitted. Such discrimination penalizes those people who need their insurance the most and creates a race to the bottom across all plans.
• Standards for Minimum Benefits[vi] – Without a baseline “floor” of benefits, patients with life- threatening or chronic diseases are left without options that cover their care. With prescribed minimum benefits, insurers have greater incentive to compete based on which plan provides the best value to consumers.
• Standards for Adequate Networks[vii] – Regardless of the breadth of benefits covered in a plan, patients will not be able to access those benefits without going through a clinician. As such, having a robust provider network that provides meaningful choice across the full range of providers and facilities is essential for patient access. Baseline standards would promote competition aimed at lowering costs and providing value.

Promote Affordability: Cancer patients often face financial burdens due to loss of income during treatment, making it difficult to afford coverage. This is particularly problematic for patients without employer-based coverage or with very low incomes. Guaranteed access to coverage is a false promise without premium assistance and cost-sharing limits that allow a cancer patient to afford to use that coverage. The following policies are essential to promoting affordability:

• Limit on Out-of-Pocket Liability[viii] – As plans increasingly shift their costs to patients, reasonable limits on out-of-pocket spending allow patients to have a stake in their healthcare without driving cancer patients into bankruptcy. Policymakers have several gaps to fill that could improve upon existing protections, such as meaningful limits on out-of-pocket spending that both cap total annual exposure to costs and distribute those costs throughout the year.
• Meaningful Premium and Cost-Sharing Assistance[ix] – Many Americans simply cannot afford the cost of monthly premium payments, high deductibles, and coinsurance for costly treatments. Without significant financial assistance with premiums and cost-sharing, even patients who rely on coverage to access lifesaving treatment would have to forgo coverage and suffer the consequences.
• Public Program Access[x] – For the most low-income Americans, private insurance will never be affordable enough to allow them to secure access to necessary treatments. Programs like Medicaid play an important role in ensuring that no cancer patient in America is left without access to the care they need.

Provide Stability: For many cancer patients, even a short interruption in their coverage can have dire consequences for their treatment and their outcomes. Policymakers must provide cancer patients with the peace of mind that every patient will have access to affordable, quality coverage, even if existing or future policymakers do not act. Given the recent history of political gridlock, cancer patients cannot afford for chaos to be the default if elected officials cannot come to an agreement. Changes to existing laws and regulations must incorporate the following principles:

• System Continuity – While considering changes to our healthcare system, policymakers must not take away the protections and assistance patients rely on today without simultaneously enacting the system improvements needed to ensure they continue to have access to the high-quality, affordable coverage they need for cancer treatment.
• Maintaining State Authority – Policymakers must not erode existing state protections that patients rely on to make their existing plans work for their needs, without providing another avenue to guarantee those protections. States should continue to have the authority to regulate plans sold to consumers in their state as a means of ensuring the availability of high quality coverage.

[i] Existing protections in this area include but are not limited to: PPACA Sec. 2702, Sec. 2703, Sec. 2705 / 42 USC 300gg- 1, -2, -4.

[ii] Existing protections in this area include but are not limited to: PPACA Sec. 2704 / 42 USC 300gg-3.

[iii] Existing protections in this area include but are not limited to: PPACA Sec. 2712 / 42 USC 300gg-12.

[iv] Existing protections in this area include but are not limited to: PPACA Sec. 2711 / 42 USC 300gg-11.

[v] Existing protections in this area include but are not limited to: PPACA Sec 1311(c)(1)(a) / 42 USC 13031.

[vi] Existing protections in this area include but are not limited to: PPACA Sec. 1302 / 42 USC 18022.

[vii] Existing protections in this area include but are not limited to: PPACA Sec. 1301(c)(1)(B) / 42 USC 13031.

[viii] Existing protections in this area include but are not limited to: PPACA Sec. 2711 / 42 USC 300gg-11.

[ix] Existing protections in this area include but are not limited to: PPACA Sec. 1401, Sec. 1402 / IRC Chapter 1(A)(IV)(C) Sec. 36B, 42 USC 18071.

[x] Existing protections in this area include but are not limited to: PPACA Sec. 2001.