CANCER LEADERSHIP COUNCIL
CLC
comments on standards for qualified health plans in 2015
(February
25, 2014)
February 25, 2014
The Honorable Marilyn Tavenner
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Ms. Tavenner:
The Cancer Leadership Council, representing cancer patients,
health care professionals, and researchers, appreciates the
opportunity to comment on the 2015 Letter to Issuers in the
Federally-facilitated Marketplace (FFM). We are pleased
that some of the standards for certification of health plans as
qualified health plans (QHP) have been modified from 2014 in a
manner that is responsive to the needs of individuals with
cancer and other serious and life-threatening illnesses.
We have comments on several of the standards for plan
certification, some of which could be strengthened to ensure
that qualified health plans provide adequate coverage for all,
including cancer patients.
As requested in the Letter to Issuers, we have organized our
comments according to the chapter and section of the letter.
Chapter 2, Section 3. Network Adequacy
We commend the decision of the Centers for Medicare &
Medicaid Services (CMS) to establish a process for determining
network adequacy that does not rely on plan accreditation and
state review. We support the decision of CMS to
undertake a “reasonable access” review of the lists of network
providers and facilities submitted by issuers. The special
focus on oncology providers, mental health providers, hospital
systems, and primary care providers is also appropriate, but the
network adequacy review cannot stop with these providers.
Cancer patients are obviously most concerned about the adequacy
of oncology provider networks, but they are also mindful of the
need for adequate networks in the other areas of focus
identified by CMS and beyond. Such provider networks are
of critical importance to assure access to high quality,
multi-disciplinary care that addresses not only cancer treatment
but also symptom management across the continuum of the cancer
experience.
Children with cancer and adults who are diagnosed with rare
cancers may find that their only appropriate care options are in
children’s hospitals or cancer centers. As part of the
network adequacy and essential community provider review, we
urge CMS to consider network adequacy standards that would
protect these vulnerable patients, essential community provider
designations for children’s hospitals and cancer centers, and
out-of-network provider access that is timely and accompanied by
cost-sharing protections.
We also note that CMS “intends to use information learned during
the network adequacy review process to assist in its
articulation of time and distance or other standards for FFM QHP
networks that CMS intends to reflect in future
rulemaking.” We strongly support this process of review
and refinement of network standards, which over time should
achieve the appropriate balance between network access and
cost. The creation of a search engine function for
consumer searches for particular providers and provider types is
especially important to cancer patients, including those with
rare cancers who may need access to out-of-network providers.
We note that the Office of Personnel Management (OPM), in its
Multi-State Plan Program Issuer Letter of February 4, 2014, has
stated that multi-state plan (MSP) issuers:
“…must have in place a
process to provide timely exceptions to ensure that consumers
who need care from out-of-network providers (because of rare or
complex medical conditions or lack of in-network providers in a
geographic area) can receive it with reasonable cost-sharing,
applying enrollee costs to the in-network out-of-pocket maximum,
and protection from balance billing.”
It is likely that cancer patients with rare or difficult-to-treat
cancers will find themselves in the position that OPM describes in
its Issuer Letter. We urge CMS to consider a requirement for
QHP issuers that is comparable to the requirement OPM proposes for
MSP issuers. The cost-sharing protections proposed by
OPM will be essential to making care out-of-network a realistic
possibility for cancer survivors, an important protection when
out-of-network care may represent the best, or even the only,
treatment option for certain cancer patients.
Chapter 3, Section 1. Discriminatory Benefit Design: 2015
Approach
The proposed CMS outlier analysis, which will compare benefit
packages with comparable cost-sharing structures to identify
cost-sharing outliers, will strengthen the agency’s analysis of
plans and provide more information about possible discriminatory
benefit designs that should be corrected. We agree with the
recommendation of CMS that the outlier analysis should begin with
(but not be limited to) inpatient hospital stays, inpatient
mental/behavioral health stays, specialist visits, emergency room
visits, and prescription drugs.
The decision to review plans for outliers based on “an unusually
large number of drugs subject to prior authorization and/or step
therapy requirements in a particular category and class” and to
require revisions of possibly discriminatory practices is a
positive
development for cancer patients for whom quality treatment may
require access to a wide range of prescription drugs, including
combination therapies and a number of different drugs in a single
class over the course of cancer treatment.
Although the standards for reviewing plans are stronger than in
2014, we note that CMS has not clearly defined discriminatory
benefit design. Such a definition is critical to making plan
reviews rigorous.
Chapter 3, Section 2. Prescription Drugs
CMS proposes that issuers be permitted to indicate whether a drug
is a “medical drug” covered under a plan’s medical benefit or a
drug covered under the prescription drug benefit. The agency
indicates that this will provide clarity regarding how drugs are
covered and will also permit issuers to include medical benefit
drugs in meeting the requirement for coverage of one drug in every
United States Pharmacopeial Convention (USP) category or class or
the same number of prescription drugs in each USP category and
class as the state’s essential health benefit-benchmark
plan. We are very concerned that this proposal would permit
issuers to consider medical benefit drugs and prescription benefit
drugs in meeting formulary adequacy standards. Allowing
issuers to meet formulary standards in this way could limit access
to cancer therapies that are provided incident to a physician’s
service and also hinder access to the most appropriate therapy for
cancer patients. If this policy is implemented, we urge that
the reviews that are undertaken to protect against discriminatory
benefit design take into account this new means of listing drugs
for the purpose of determining formulary adequacy.
Because CMS will permit but will not require issuers to identify
prescription benefit drugs, consumers will not necessarily be able
to compare medical benefit drug coverage across plans.
We are pleased that CMS will require issuers to provide a URL link
that will direct consumers to an up-to-date formulary where they
can view covered drugs, tiering, and cost-sharing for a given
QHP. For those consumers who are already diagnosed with
cancer, the availability of up-to-date formulary information will
permit them to make informed plan choices. Those who are
diagnosed with cancer AFTER making a plan choice will obviously
not benefit from formulary information in the same way. The
situation of those diagnosed after choosing a plan serves as a
reminder of the need for protections to ensure that formularies
are adequate to meet the needs of those with serious and
life-threatening illnesses who need timely access to
pharmaceuticals. In addition, the formulary comparisons will
be hindered if some issuers identify medical benefit drugs and
others do not.
CMS has stated that it will propose by rulemaking that issuers
provide transitions in drug coverage as well as coverage
transitions for other types of care, including continuity of
access to specialists for individuals in the midst of a course of
cancer treatment. In the letter to issuers, CMS suggests a
standard for coverage of a “transitional fill” of non-formulary
drugs to new enrollees in a health plan. We will comment on
the proposed rule that addresses transitions in care, providing
more detail about the length and nature of transitions that are
necessary to ensure continuity of care for cancer patients.
We note that the proposal from CMS for transitional fills and
access to specialists will not address issues of care continuity
unless patients are notified that the care they are receiving is
transitional and that they must initiate an exceptions process
immediately to prevent disruptions in care after the transitional
period.
Continued access to cancer specialists and to cancer medications,
which are not readily interchangeable and are often prescribed
according to an individual’s tumor and molecular profile, may help
patients complete their course of treatment and achieve better
outcomes. Preventing interruptions in care is of critical
importance to cancer patients, and steps must be taken to ensure
that the CMS proposal does not simply delay disruptions in care.
Chapter 3, Section 7. Coverage of Primary Care:
2015 Approach
We encourage CMS to move forward with rulemaking that would
require plans, or at least one plan at each metal level per
issuer, to cover three primary care office visits prior to meeting
any deductible. We believe that this coverage standard would
contribute to improvements in survivorship care for cancer
patients, including but not limited to young adult cancer
survivors. Regular monitoring of the late and long-term
effects of cancer treatment and interventions to address those
effects are critically important, yet some survivors delay this
care. Ready access to primary care may positively influence
utilization of such survivorship services.
Chapter 6, Section 1. Provider Directory
We support the requirement that qualified health plans make their
provider directories available to consumers. We urge that
the directories provide up-to-date information, so that consumers
can make decisions about providers with assurance that they are
relying on accurate data about network status of those
providers. These decisions have important financial
implications, and there should be no delays in updating the
information in the directories.
Chapter 6, Section 2. Complaints Tracking and Resolution
The letter to issuers clearly establishes expectations for QHP
performance related to the investigation and resolution of
consumer complaints. The letter establishes that complaints
received directly from consumers, complaints forwarded by the
state, and complaints forwarded by CMS through the Health
Insurance Casework System must be promptly resolved. In
addition to articulating complaint resolution standards, CMS has
stated that it will track complaints and use aggregated data
about complaints to enhance oversight of federally-facilitated
marketplaces. We applaud this effort, which will contribute
to improvement of QHPs over time.
**********
We appreciate the opportunity to comment on the letter to plan
issuers for 2015.
Sincerely,
Cancer Leadership Council
American Society for Radiation Oncology
American Society of Clinical Oncology
Bladder Cancer Advocacy Network
CancerCare
Cancer Support Community
The Children’s Cause for Cancer Advocacy
Coalition of Cancer Cooperative Groups
Free to Breathe
International Myeloma Foundation
Leukemia & Lymphoma Society
LIVESTRONG Foundation
Lymphoma Research Foundation
National Coalition for Cancer Survivorship
Ovarian Cancer National Alliance
Pancreatic Cancer Action Network
Prevent Cancer Foundation
Sarcoma Foundation of America
Us Too International Prostate Cancer Education and Support Network