March 20, 2013 - More than a dozen patient advocacy organizations, patients and health providers are locking arms this Thursday, to work to ensure more predictable health care costs for Oregonians covered under commercial and community health plans. Senate Bill 165 establishes a stop-loss requirement, which will limit out-of-pocket costs by adding the definitions for “cost-sharing” and “essential health benefits” to Oregon’s Insurance Code. The legislation will limit cost-sharing amounts that may be required under health benefit plans to a monthly cost not to exceed$495.34 for a single enrollee or a monthly cost not to exceed $995.84 for plans that cover families or multiple enrollees.
This bill, if passed, will apply to commercial, small group and individual plans when policies and certificates are issued or renewed on or after January 1, 2014. Five organizations are co-requestors on the bill: Cascade AIDS Project; National Multiple Sclerosis Society - Oregon Chapter; Hemophilia Foundation of Oregon; Molly’s Fund Fighting Lupus; and Oregon Diabetes Educators.
“This is really important to patients and families across the state as it means Oregonians’ health insurance and benefit plans, especially prescription costs, will have monthly caps, aligning with the annual cost caps provided in the federal Affordable Care Act,” said patient John Motter, who is also a program coordinator working with HIV-positive individuals at Cascade AIDS Project. He adds, “Although labs and doctor visits can be numerous, monthly copays for medicine can be prohibitive depending on your specific benefit plan.”
The Affordable Care Act mandates annual out-of-pocket cost caps for those plans in the health insurance exchange, while this Oregon legislation will apply to the full range of commercial plans, to close the gap so out-of-pocket, monthly cost caps are in place. Similarly structured caps on out-of-pocket costs are also already in place for Medicare’s prescription drug benefit.
“This will really benefit me and so many people like me,” said 40-year-old arthritis patient and busy southeast Portland resident, Megan Helzerman. She shares that her out-of-pocket cost-sharing arrangement for her medicines continues to increase year over year. “Now, my insurance continues to cover 80 percent of the treatment. I continue to pay $600 per month, but my out-of-pocket maximum just doubled to $2,400. I reached it in four months in my current plan year.”
Like Helzerman, those who need terminal and chronic care medicines often are the most financially at risk because insurers implement high cost-sharing mechanisms such as ‘specialty tiers.’ These tactics implement prohibitive co-insurance structures that punish the patients and families that most need limits on out-of-pocket costs.
Organizations are currently supporting this legislation, which will be heard before the Senate Health Committee on Thursday, March 21 at 3 p.m., include Hemophilia Foundation of Oregon; National Multiple Sclerosis Society - Oregon Chapter; Molly's Fund Fighting Lupus; Cascade AIDS Project; Oregon Diabetes Educators; Arthritis Foundation of Oregon; and American Cancer Society of Oregon. Testimony in support is encouraged.
