Insurers May Be Restricted From Covering Transplants for Two Years

The previously uninsured can expect to wait up to two years for even pre-op care unless Oregon’s Insurance Commissioner issues a rule change by Jan. 1

 

October 10, 2013 -- Cover Oregon begins in only a few months. But those needing an organ transplant who haven’t had prior coverage may have to wait a lot longer.

Oregon’s implementation of the Affordable Care Act requires a 24-month waiting period on organ transplants for people who’ve been uninsured for the past two years, a requirement that’s frustrating doctors and hospital administrators.

“I don’t understand the rationale for denying people the most effective treatment for no apparent clinical reason, except for ignorance,” said Dr. William Bennett, Legacy Health’s medical director.

Oregon Insurance Commissioner Laura Cali said the waiting period is actually a holdover from the pre-Affordable Care Act era. Oregon’s essential benefits package was modeled on the PacificSource Small Group Plan from 2012, which included a moratorium on organ transplants to avoid attracting sick customers.

Cali acknowledged her office “knew the issue was important,” and was “looking very hard at how to resolve it,” but refused to offer any details on the investigation, or say whether a decision will be made before Cover Oregon’s Jan. 1st kickoff date.

Lisa Morrison, the waitlist coordinator for Legacy Health, said there are two patients on the waiting list for a kidney transplant that will be affected if the waiting period isn’t changed before January, and Legacy has deferred evaluating several other patients until more information is available.

Up to 12 patients on the solid organ transplant waiting list will be temporarily inactivated, according to OHSU spokesperson Tamara Hargens-Bradley, as well as four patients in the bone marrow transplant evaluation process.

If the waiting period is not modified before Jan. 1, both Legacy and OHSU plan to file an appeal with the Insurance Division.

Legacy specializes in kidney transplants, which Bennett says is the institution’s preferred treatment choice for end stage renal disease, commonly known as kidney failure, and a quick transplant is favored for both medical and financial reasons. Dialysis is the stopgap treatment for kidney failure. Bennett said that the longer a patient undergoes dialysis treatment the less likely a future kidney transplant will take, a claim supported by medical literature. Kidney transplants cost about $100,000 at Legacy. Dialysis from the treatment’s two primary providers in Oregon -- DaVita and Fresenius Medical Care- costs roughly the same amount every year.

The exclusion on transplants only affects people who’ve been uninsured for two years. Anyone else who purchases insurance through Cover Oregon can have a transplant if it’s medically necessary and a donor organ is available. Children are also subject to the two-year waiting period.

Morrison said that most of her patients either have private insurance, or were covered by Medicare/Medicaid. “This will disproportionately hit those who are undocumented, and young people.”

Mike Seely, the executive director for organ procurement transplant services at OHSU, said the waiting period poses a more direct medical risk to people in need of heart or liver transplants.

"If I am a new enrollee in an ACA insurance plan, and by some twist of fate I experience sudden end-stage heart or liver failure which requires a transplant, my life may well be in jeopardy because the current provisions delay the option of this therapy for two years,” he said.  

Legacy first voiced its concern about the waiting period almost a year ago. Last November Legacy Vice President Tony Melaragno wrote a letter to then-Oregon Insurance Commissioner Lou Savage, urging him to “exclude a waiting period for kidney transplant benefits.”

When the issue was raised again at a Cover Oregon board meeting last month, Rocky King, its executive director, said the issue had “just come up.”

In a phone interview King said he hoped Cali and the Oregon Insurance Division are able to renegotiate the waiting period before January, but said that the issue was out of his hands.

King hopes the waiting period does not deter people from signing up for insurance.

There has been no industry standard waiting period for organ transplants among health insurers.

Washington State has imposed a six-month waiting period on organ transplants as part of its implementation of the Affordable Care Act while California has no waiting period.  

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