Across the country, more than 78 million people lived within families in which someone lost their job between March and May of this year, according to a Kaiser Family Foundation Report. Among those families, at least 61 percent, or 47.5 million, were covered by employer-sponsored health insurance.
At the same time, employers are looking for ways to lower healthcare costs and are increasingly turning to utilization management strategies like site of care restrictions.
In this issue, we look at the options and resources available to those who have lost or will lose their healthcare coverage, as well as the trend for payers to adopt site of care policies.
COVID-19 AND THE LOSS OF EMPLOYER SPONSORED HEALTHCARE INSURANCE 1, 2
A recent Kaiser Family Foundation (KFF) analysis estimated that as of May 2, nearly 27 million Americans may lose their employer sponsored insurance (ESI) following the loss of a job. Similarly, in early May, the Robert Wood Johnson Foundation (RWJF) projected that an estimated 25-43 million people could lose their employer-sponsored health insurance coverage.
The KFF and RWJF analyses, estimate that of those who lose ESI through the loss of their employment or that of a family member, 70% to 80% will be eligible for Medicaid or subsidized coverage through the Affordable Care Act (ACA) Marketplace. The remainder will have to find coverage elsewhere or remain uninsured.
Options for those who have lost their insurance through unemployment or loss of income, and don’t have access to coverage under a family member’s health plan, include enrolling in Medicaid, purchasing coverage offered in the ACA’s Marketplace, or continuing coverage under COBRA. Short-term health insurance plans are relatively inexpensive but they are not feasible for many individuals as pre-existing conditions are not covered.
Enrolling in Medicaid
Enrolling in Medicaid may be the best option for those who lose their job and health coverage and who live in states that expanded Medicaid under the ACA. In states that expanded Medicaid, eligibility is extended to most low-income individuals with incomes at or below 138% of poverty ($17,236 in 2019).
However, in states that have not expanded Medicaid, eligibility is extremely limited (the median income limit for these states is 40% of poverty), and in nearly all of these states childless adults are ineligible for Medicaid regardless of how low their income is. As of July 1, 2020, thirty-eight states (and DC) have adopted Medicaid expansion, while thirteen states have not (Figure 1).
On Tuesday, June 30, 2020 citizens in Oklahoma voted to expand Medicaid under the ACA by amending the state constitution. Under this expansion, those who earn up to 138% of the federal poverty level (approximately $17,200 for individuals and $35,500 for families) will now qualify for Medicaid. Missouri voters will also decide on a constitutional amendment to expand Medicaid in their state on August 4, 2020. 3
Undocumented immigrants are ineligible for Medicaid, and recent immigrants (those here for fewer than five years) are ineligible in most cases. 4
In all states, Medicaid enrollment is open all year.
Figure 1. Source: KFF.org. Status of State Medicaid Expansion Decisions
ACA MARKETPLACE 5
Marketplace Open Enrollment Extensions
In most states, the annual Open Enrollment period for the ACA Marketplace runs from November 1, to December 15. However, states that run their own ACA health insurance Marketplace (State-based Marketplaces or SBMs) have flexibility in their open enrollment schedule and several SBMs have longer open enrollment periods.
In addition, twelve of the thirteen states that operate their own SBMs established special-enrollment periods due to COVID-19, to make sure that previously uninsured individuals and those losing coverage have a source of healthcare coverage which is critical during the pandemic.
States whose extended enrollment periods were still open as of this writing include the following states:
In contrast, the 38 states that are run by the federal government (Federally-facilitated Marketplaces or FFMs) did not establish a special COVID-19 enrollment period, as the administration decided not to reopen HealthCare.gov, the platform through which consumers in FFM states apply for and enroll in ACA plans.
Marketplace Special Enrollment Period 6
Outside of open enrollment, plan changes and new enrollments are only possible for people who experience a qualifying event that allows them to enroll under a Special Enrollment Period (SEP), with the exception of Native Americans (of federally recognized tribes) and Alaska Natives who can enroll year-round in plans offered in the health insurance Marketplaces. 7
Under the ACA, people who experience certain qualifying life events (QLE) qualify for a SEP, allowing them to sign up for a Marketplace health insurance plan without waiting for the open enrollment period. The Centers for Medicare & Medicaid Services (CMS) lists the following 4 basic types of (QLE) and examples:
- Loss of health coverage – you may qualify for a SEP if you or anyone in your household lost qualifying health coverage in the past 60 days or expects to lose coverage in the next 60 days including:
- Losing existing health coverage, including job-based, individual, and student plans
- Losing eligibility for Medicare, Medicaid, or CHIP
- Turning 26 and losing coverage through a parent’s plan
- Losing coverage through a family member
- Changes in household – you may qualify for a SEP if you or anyone in your household in the last 60 days:
- Got married
- Got divorced or legally separated and lost health insurance
- Had a baby or adopted a child
- Had a death in the family and resulted in loss of current health plan
- Changes in residence – household moves that qualify you for a SEP include:
- Moving to a different ZIP code or county
- Moving to the U.S. from a foreign country or U.S. territory
- A student moving to or from the place they attend school
- A seasonal worker moving to or from the place they both live and work
- Moving to or from a shelter or other transitional housing
- Other qualifying events – the following events may qualify you for a SEP:
- Changes in your income that affect the coverage you qualify for
- Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
- Becoming a U.S. citizen
- Leaving incarceration (jail or prison)
- Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member
Applicants may be asked to submit certain documents to confirm the events that qualify the applicant for special enrollment, such as proof of prior job-based coverage. Eligible applicants will be notified of the documents they must submit and they will have 30 days to send the requested documents.
In general, people have 60 days after they lose their job-based insurance to use that as a reason to qualify under an ACA special enrollment period. However, people who otherwise qualified for a special enrollment but failed to sign up within the 60-day window because they were impacted by the COVID-19 emergency (if you were sick with COVID-19 or were caring for someone who was sick with COVID-19), might be eligible for another special enrollment period.8
In June 2020, CMS released a trends report that provides data on the number of individuals who signed up for coverage on HealthCare.gov from the end of the Open Enrollment Period (OEP) through May of the 2017-2020 coverage years using existing SEPs. The report shows that in 2020, 486,954 consumers who lost job-based healthcare coverage used the SEP to enroll in coverage through FFMs using the HealthCare.gov platform, an increase of 188,000 over 2019 (Figure 2). 9
The CMS report does not include information on the number of consumers who signed up for coverage during an extended enrollment or SEP enrollment in the states that run their own health insurance Marketplace. And it does not include those who enrolled through a SEP after May.
Figure 2. Source: CMS.gov. SEP Enrollment from the end of Open Enrollment through May, 2017-2020 Coverage Years.
For more information on the ACA SEP access the CMS brochure, Understanding Special Enrollment Periods at:
Enrollment Figures Show Increase in Lower Level Health Plans
In the ACA Marketplaces, there are four levels of health plans: Bronze, Silver, Gold and Platinum. Each of the four levels covers the same set of essential health benefits (EHBs). The four levels are differentiated based on how enrollees and the insurance plan split the costs of covered benefits (the actuarial value). The higher the actuarial level, the more the plan pays towards the enrollee’s health care expenses, this includes deductibles, copayments and coinsurance. As would be expected, plans with higher actuarial values also have higher premiums. 10
Figure 3. Source: HealthCare.gov. The "metal" categories: Bronze, Silver, Gold & Platinum.
Even before the COVID-19 pandemic and the resulting economic downturn and loss of jobs, ACA enrollment was trending to consumers choosing lower level tier plans, Bronze and Silver, rather than the higher tiers, Gold and Platinum, which have higher premiums. During open enrollment in 2020, 33% of enrollees chose a Bronze level plan (enrollees pay 40% of covered benefit costs), and 57% chose a Silver level plan (enrollees pay 30% of covered benefit costs) for a total of 90% of enrollees in plans with out-of-pocket costs of at least 30% (Figure 4). 11
Figure 4. Source: KFF.org Marketplace Plan Selections by Metal Level
Although only 1% of enrollees chose the limited coverage Catastrophic plans, this number may increase especially among those who don’t qualify for Medicaid or Marketplace subsidies. Catastrophic plans are only available for people under age 30, and people of any age who qualify for a hardship exemption. Monthly premiums for these plans tend to be lower, but generally, enrollees must pay for all health care costs until they meet a high deductible. For 2020, the deductible for all Catastrophic plans is $8,150. Enrollees in Catastrophic plans cannot get premium tax credits or out-of-pocket subsidies.
ACA Marketplace Subsidies 12
Premium Tax Credits
Many of those who lost their employer-based health insurance through loss of employment or income may find that they qualify for subsidies to reduce monthly premiums and/or out-of-pocket costs for plans offered through the health insurance Marketplace. The ACA offers two types of subsidies, premium tax credits and cost-sharing subsidies.
The premium tax credit reduces Marketplace enrollees’ monthly premium payments for plans purchased through the Marketplace. The premium tax credit can be applied toward any plan sold through the Marketplace (with the exception of catastrophic coverage).
To qualify for the premium tax credit in 2020, the Marketplace enrollee must meet the following criteria:
- Have a household income between 100% and 400% of the Federal Poverty Level (FPL), which for the 2020 benefit year will be determined based on 2019 poverty guidelines (In 2020, the subsidy range in the continental U.S. is from $12,490 for an individual and $25,750 for a family of four at 100% FPL, to $49,960 for an individual and $103,000 for a family of four at 400% FPL)
- Not have access to affordable coverage through an employer (including a family member’s employer)
- Not be eligible for coverage through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or other forms of public assistance
- Have U.S. citizenship or proof of legal residency (lawfully present immigrants whose household income is below 100% FPL and are not otherwise eligible for Medicaid are eligible for tax subsidies through the Marketplace if they meet all other eligibility requirements.)
- If married, must file taxes jointly in order to qualify
In addition to the premium tax credit, a cost-sharing subsidy may also be available to Marketplace enrollees. Cost-sharing subsidies reduce a person or family’s out-of-pocket cost when they use health care services, such as deductibles, copayments, and coinsurance. People who are eligible to receive a premium tax credit and have household incomes from 100% to 250% of poverty are eligible for cost-sharing subsidies. However, cost-sharing subsidies can only be applied toward a silver plan.
Under the ACA, without the cost-sharing subsidy, the 2020 maximum out-of-pocket (OOP) spending is limited to $8,150 for an individual and $16,300 for families. With the cost-sharing reduction, the out-of-pocket maximum can be no higher than $2,700 to $6,500 for an individual, or $5,400 to $13,000 for a family in 2020, depending on income.
In general, silver plans have an actuarial value of 70%, this means that on average, the plan pays 70% of the cost of covered benefits and the enrollee pays the remaining 30% through deductibles, copayment and/or coinsurance. The cost-sharing subsidies lower the enrollee’s out-of-pocket costs which increases the actuarial value of the silver plan. Figure 3, shows the reduced out-of-pocket maximums and increased actuarial values after cost-sharing subsidies are applied, based on income as a percentage of the federal poverty level.
Maximum Annual Limitation on Cost-Sharing
|(% Federal Poverty Level)
of a silver plan
|OOP Max for
||$7,900 / $15,800
||$8,150 / $16,300
|100% - 150%
||$2,600 / $5,200
||$2,700 / $5,400
|150% - 200%
||$2,600 / $5,200
||$2,700 / $5,400
|200% - 250%
||$6,300 / $12,600
||$6,500 / $13,000
||$7,900 / $15,800
||$8,150 / $16,300
Figure 5. Source: "Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2020," Federal Register 83 FR 16930.
Unfortunately, in states that have opted out of the Medicaid expansion under the ACA, a coverage gap exists when individuals are both ineligible for Medicaid (because they have too much income to qualify for Medicaid), and are below the poverty level (which is the minimum eligibility threshold for Marketplace subsidies under the ACA).
Cobra Coverage 13, 14
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), many people who lose their health benefits have the right to choose to temporarily continue group health benefits provided by their group health plan. Generally, qualified individuals have 60 days to sign up for COBRA coverage. But a new rule extends the enrollment period to 60 days after the COVID-19 national emergency ends. When an individual does elect COBRA coverage, they are responsible to pay any back premiums between the time they lost coverage to when they signed up.
Coverage under COBRA is generally very expensive as qualified individuals are often required to pay the entire premium for coverage and a 2% administration fee. For this reason, people who qualify for Medicaid or subsidized coverage under the ACA Marketplace often choose that coverage over COBRA.
However, COBRA coverage might be an option for those who are under active treatment, as they can continue to see their doctors, can continue with their current treatment, and would not face new deductibles. Under COBRA, the coverage must be identical to the coverage currently available under the plan to similarly situated active employees and their families (generally, this is the same coverage the individual had immediately before the qualifying event).
A recent Kaiser Health News article raises the concern expressed by some policy experts that extending the time to sign up for COBRA (allowing individuals to wait and sign up only if they become ill) leaves the door open for hospitals or other providers to offer to pay sick patients’ back premiums so their treatment would be covered through COBRA. 15
AVAILABLE ASSISTANCE FOR PATIENTS
Manufacturer Patient Support Programs
In addition to third-party patient assistance programs (which have limited funds available and often close enrollment soon after opening), many pharmaceutical companies have programs to help patients who don’t have insurance coverage or who have difficulty paying for their drugs.
In general, eligibility is based on medical insurance status and annual income. Each company sets their own income eligibility criteria, usually based on percentage multiples of the federal poverty level. Patients who have lost coverage or whose income is lower now than that listed on their tax return should be prepared to include information describing their current insurance and financial status.
Many of the manufacturer patient assistance programs have expanded the resources available to accommodate the growing need of patients who have lost their job and/or health insurance due to COVID-19.
And, as the impact of the COVID-19 pandemic continues to be felt across the nation, organizations are stepping-up to provide assistance. Below are a few of the new programs (that were still open to new enrollees as we went to print) that may be helpful to patients impacted by COVID-19:
The Assistance Fund Health Insurance Assistance Program
In response to the coronavirus pandemic (COVID-19), The Assistance Fund (TAF) has launched a new health insurance assistance program for eligible individuals who have experienced a disruption in their coverage due to the pandemic.
The COVID-19 Health Insurance Assistance Program provides financial support for eligible TAF patients by offering grants of up to $2,500 to help them secure health insurance for the remainder of 2020. Applicants will be required to submit verification that they lost insurance, purchased new insurance or are paying for a continuation of their previous insurance, and proof of economic hardship.
To be eligible, the individual must be actively enrolled or have been enrolled in a TAF copay program in 2020; must have filed a claim in 2020; must not be currently enrolled in a TAF financial assistance program; and must meet the following additional criteria:
- Be a legal resident of the United States or a US territory, and must fall within household-income and household-size financial guidelines based upon the Federal Poverty Level.
- The TAF patient’s insurance coverage must have been impacted by a COVID-19-related job loss.
- Must have secured or be in the process of securing replacement insurance (or must be paying directly for continuation of existing insurance).
- Must submit a complete program application that includes the patient’s attestation.
For more information and to apply online go to: tafcares.org/covidprogram/
Colorectal Cancer Alliance (CCA) Crisis Financial Assistance Fund
The CCA provides up to $200 in emergency financial assistance that can be used for rent, groceries, utilities, food, transportation, etc. The CCA funds are available to low-income, US residents (excluding Puerto Rico and other US territories), with a household income no more than $75,000/year who are receiving treatment for colorectal cancer, and who have not received previous financial assistance from CCA. To apply, call 877-422-2030 or apply online at: ccalliance.tfaforms.net/19.
LUNGevity Breathe Easier Emergency Response Fund
The Breathe Easier fund will offer financial assistance to eligible lung cancer patients and their families to satisfy their critical basic needs of food, transportation, and general household bills during the COVID-19 public health emergency. Support in the amount of $500 will be provided to eligible patients and their families during the COVID-19 public health emergency.
To qualify, applicants must meet the following criteria:
- Patients must be in active treatment, or actively pursuing treatment, for lung cancer.
- The patient’s household income does not exceed 300% of the Federal Poverty Level (FPL); however, special consideration will be given to those who are recently unemployed or furloughed as a result of COVID-19.
- Patient must be a US resident and be receiving care for lung cancer in the US.
Call the Lung Cancer HELPLine (844-360-5864), to learn more and apply for support. For more information: lungevity.org/for-patients-caregivers/covid-19-and-lung-cancer/breathe-easier-emergency-response-fund.
Lymphoma Research Foundation COVID-19 Financial Assistance Grant
The Lymphoma Research Foundation's COVID-19 related financial assistance provides limited financial assistance for people with lymphoma/CLL in active treatment to help with costs including food, transportation, lodging or housing, utilities, childcare, and/or devices (e.g., canes, wheelchairs, ramps, air filters).
In order to be eligible for financial assistance applicants must:
- Have a diagnosis of lymphoma or CLL confirmed by an oncology health care provider (Physician Referral Form must be completed)
- Be in active treatment for cancer or received treatment within the last 6 months
- Live and be a legal resident of the U.S
- Have a household income that is at or below 500 percent of the U.S. federal poverty guidelines
For more information: lymphoma.org/learn/supportservices/financialsupport/
Rx Outreach Special Enrollment
Rx Outreach is a non-profit mail order pharmacy. Membership is traditionally reserved for those earning less than 400% of the Federal Poverty Level, but RX Outreach is temporarily expanding the guidelines on their medication program to assist individuals and families who are facing severe financial hardships because of COVID-19. For more information and to apply online go to: https://rxoutreach.org/covid19/.
The Sontag Foundation COVID-19 Emergency Assistance Fund
The Sontag Foundation COVID-19 Emergency Assistance Fund offers qualified applicants up to $500 in emergency financial assistance.The funds may be used for food/groceries, utilities, rent/mortgage, car payments/transportation expenses, temporary lodging, or child care.
Individuals or caregivers of individuals with confirmed brain tumor diagnosis in active treatment, scheduled to begin treatment in the next 60 days or have been in treatment in the last 6 months may be eligible. Applicants must be US citizens or permanent residents who live in the US or US territories. And the patient or caregiver must have been impacted by COVID-19 or the related economic uncertainty. Apply by calling 855-824-7941, choose option 5.
SITE OF CARE POLICIES 16
Oncology clinics across the country are reporting an increasing number of payer site of care policies for infused specialty drugs including chemotherapy and immunotherapy. As an example, effective July 1, 2020, Aetna’s Drug Infusion/Injection Site of Care Policy includes oncology immunotherapy drugs in their list of drugs which requires (with certain exceptions) the use of non-hospital outpatient facilities (physician office, ambulatory infusion centers, home care) after the first 45 days of therapy.
Oncology immunotherapy drugs listed in the Aetna July 1, 2020 policy update include:
- Nivolumbab (Opdivo®)
- Pembrolizumab (Keytruda®)
- Ipilimumab (Yervoy®)
- Durvalumab (Imfinzi®)
- Cemiplimad (Libtayo®)
- Avelumab (Bevencio®)
- Atezolizumab (Tecentriq®)
According to Aetna, this policy will only apply to commercial patients on monotherapy. The policy does not apply to Medicare patients. Access the Aetna policy here: www.aetna.com/health-care-professionals/utilization-management/drug-infusion-site-of-care-policy.html.
Other national payers have also implemented expanded site of care policies for specialty medication infusion services. The May 2020 UnitedHealthCare (UHC) Provider Bulletin includes an updated Provider Administered Drugs – Site of Care Guideline Number: URG-9.14. This policy specifies the criteria that meets medical necessity for infusion of certain specialty drugs in the hospital outpatient facility (includes place of service codes 19 Off Campus Outpatient Hospital, and 22 On Campus Outpatient Hospital). If the criteria are not met, UHC says alternative sites of care may be used, such as non-hospital outpatient infusion centers, physician offices, ambulatory infusion centers, or home infusion.
Access the May UHC Provider Bulletin here: www.uhcprovider.com/content/dam/provider/docs/public/policies/index/commercial/provider-administered-drugs-soc-07012020.pdf.
In other cases, payers will allow for infusion for certain specialty drugs in the hospital outpatient department when the payer and hospital have agreed upon reduced reimbursement rates for the drugs, or if the drugs are obtained through the payer’s specialty pharmacy.
It’s helpful to understand why site of care policies have come about, and the intent of these policies. The trend of independent physician offices closing or being purchased by hospitals, brought into focus the cost of care in hospital outpatient departments (HOPDs) versus the cost of the same service in the physician office (PO). Over the last few years, studies comparing the cost of certain services, including administration of specialty drugs, in physician offices instead of hospital outpatient departments have shown a significant savings when providing these services outside the hospital.
The January 16, 2020, Employee Benefit Research Institute (EBRI) Issue Brief Cost Differences for Oncology Medicines Based on Site of Treatment examines earlier research demonstrating that payments from third-party payers for infused oncology medicines are higher when care is provided in HOPDs compared with POs. The EBRI study concludes that payments for infused cancer medicines in the commercial and employment-based markets are nearly two times higher, on average, in the HOPD relative to the PO for the same drug and that these cost differences are due to pricing decisions of hospitals, not differences in modality. The study authors state, “Given that nearly half of oncology therapy takes place in HOPDs, employers could cut their drug costs nearly in half simply by shifting patients to PO settings without necessarily affecting quality of care. They could also negotiate site- neutral pricing for medicines.” 17
A September 2019 UnitedHealth Group report states that administering specialty drugs outside hospitals could reduce costs by $4 billion each year. According to the report, administering chemotherapy in settings outside of hospitals would provide a $16,000 savings for four months of treatment.
Nevertheless, these policies may impede or delay patient access to care when preferred sites of care are not easily accessible to the patient. And oncology centers need to stay aware of payer policies, including site of care policies, in order to mitigate reimbursement denials. Prior authorization personnel must make sure that both the drug and the intended infusion site are authorized.