Health Plans Must Not Discriminate Against Patients with Cancer, ASCO States in Letter to CMS

January 4, 2018

On December 27, ASCO sent a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma to reiterate the society’s Principles for Patient-centered Health Care Reform and to weigh in on the proposed notice, “Patient Protection and Affordable Care Act; Health and Human Services (HHS) Notice of Benefit and Payment Parameters for 2019.”

In its letter, ASCO expressed concerns that the proposed notice would fundamentally alter many of the consumer and patient protections in individual and small group markets and lead to the establishment of qualified health plans that would fail to address the comprehensive medical needs of patients with cancer.

ASCO outlined the following specific concerns:

  • New Benchmarking Rules. Under current law, states must establish a required essential health benefit (EHB) benchmark plan, outlining the EHBs that all individual and small group market plans must cover. The proposed notice would allow states to adopt all or part of an EHB plan from another state, or to select a set of benefits to define a new EHB benchmark, as long as those benefits are no more generous than existing EHB benchmark options. ASCO is concerned that this change would create incentives for states to select less generous benchmarks, which could make it more difficult for people with cancer to have comprehensive coverage.
  • EHB Benefit Substitution. The proposed notice would allow plans to substitute benefits from one EHB category for another, without regard for medical similarity. This may leave certain EHB benefit categories without adequate coverage levels for people with cancer.
  • National EHB Standard. ASCO reiterated its longstanding position that any national EHB standard must guarantee robust and meaningful access to cancer care, including mandatory prescription drug coverage of each unique molecular entity used in cancer treatment.
  • Network Adequacy Standards. In its letter, ASCO urged the Administration to implement federal protections so that health plans provide access to an adequate number of oncology providers.

ASCO President Bruce Johnson, MD, FASCO, writes, “It is critical that the federal government employ active and continuous oversight to ensure that plans do not discriminate against cancer patients.  A discriminatory plan is one that fails to provide benefits that are consistent with well-established standards of care or does not include sufficient access to cancer specialists that provide the full range of cancer care services.”

Read the full letter.

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