An Update From the States

An Update from the States

In an ongoing effort to keep you up to date on the many proposed and approved changes to our health care system and how they might impact the cancer community, this week, we bring you updates from around the country. If you don’t live in one of these states, be aware, these changes could come to your state next. 

Medicaid News:

Do you have Medicaid coverage? You can now access the services included in Amazon Prime for a discounted fee of $5.99 a month, less than half the regular cost of $12.99 a month. Access to Prime services, including free expedited shipping, can be particularly useful for someone who is treatment. Instead of having to go grocery shopping or running other errands for household items, Amazon Prime can deliver those items to your doorstep for free. Amazon also now offers electronic benefit transfer (EBT) cards, which are used for food stamp benefits.

Other National News:

In the recent Bipartisan Budget Act of 2018, passed by Congress on February 9th, there were several changes made to our health care system that may be helpful and challenging for the cancer community:

  1. It provided two additional years of funding to State Health Insurance Assistance Programs (SHIP) and Area Agencies on Aging, which are two valuable resources that help seniors manage their Medicare coverage and get access to other programs and services.
  2. It eliminated the Medicare cap on access to outpatient physical, occupational, and speech therapy services as of January 1, 2018.
  3. It closed the Medicare Part D donut hole one year earlier in 2019, lowering the cost of prescription drugs for people with Medicare.
  4. It also changed the way that Medicare pays for home health services beginning in 2020. The home health coverage will be reduced from 60 days to 30 days and therapy thresholds will be eliminated. Beginning in 2019, Medicare will be allowed to base eligibility for home health services on a review of a patient’s medical record, including a home health agency’s record.


The Hawaii House has approved a bill that would allow physicians to prescribe life-ending medication to terminally ill patients. The bill now moves to the Senate, which approved a similar bill laws year. If approved, Hawaii would join California, Colorado, Oregon, Vermont, Washington, and the District of Columbia, which have death with dignity laws. Click here for more information about state laws.


A few weeks ago we shared that the Idaho Governor announced that he will allow insurance companies to sell plans in violation of the Patient Protection and Affordable Care Act (ACA). The ACA required health insurance plans to meet certain minimum requirements in order to protect consumers from pre-existing condition exclusions and annual and lifetime limits, while ensuring coverage of essential health benefits.

This past week, the Trump Administration did reject Idaho’s plan to sell plans in violation of the ACA.  Many other states had been closely watching this decision, as they also were looking at allowing plans without the ACA consumer protections. The cancer advocacy community was pleased to see that these consumer protections wouldn’t be ignored. However, the Administration did suggest to Idaho that they instead promote the sale of short-term insurance plans. Click here for more information on these plans.


The Iowa Senate voted last week to let the Iowa Farm Bureau Federation and Wellmark Blue Cross & Blue Shield sell health insurance plans that don’t comply with the ACA, allowing people with pre-existing conditions to be denied or charged more for coverage.  Given the Administration’s rejection of Idaho’s plans, it is likely that Iowa will not be able to move forward with the sale of these plans.


There was a question as to whether or not Arkansas’ legislature was going to keep their expanded Medicaid program. However, lawmakers did vote to keep the program that covers 285,000 people in Arkansas another year.

In addition, the Trump Administration has approved Arkansas’ request to add a work requirement to their Medicaid program, joining Indiana and Kentucky as states that have added this new requirement. There are seven other states that have submitted applications for a Medicaid work requirement and 14 other states that are considering it.

Stay tuned for the latest news  . . .

Health Care in the News: Keeping Down Costs

  1. Cost-Sharing Reductions: On Thursday, 10/12, the President announced the discontinuation of cost-sharing reduction payments (CSRs) for health insurers that sell plans in the state Health Insurance Marketplaces.
    • For those who choose to buy health insurance coverage through the marketplaces, they may be eligible for 2 types of financial assistance: 1) premium tax credits; and 2) cost-sharing reductions. Premium tax credits reduce your monthly premium payment for whichever plan you choose to buy in the marketplace. Cost-sharing reductions are a requirement in the ACA, that insurance companies lower the cost of deductibles, co-payments, and co-insurance amounts on silver level plans, based on your income level. The cost-sharing reductions are provided by the insurance company, but are reimbursed by the federal government.
    • Since taking office, the President has indicated that he might end the CSRs. His lack of a definitive decision creative uncertainty for insurance companies in determining their rates for plans sold in the marketplace for 2018. This uncertainty actually cause may insurers across the country to choose not to sell plans in the marketplace for 2018, which ultimately reduces competition and increases rates for the plans that are sold in the marketplace. Some companies decided to continue to sell their plans, but increased their rates, to cover the loss of the CSR payments from the federal government.
    • It now falls on Congress to fund the CSR payments for 2018 and beyond. There is currently a proposal being discussed in the Senate to fund the CSR payments for two years, but it includes other changes (see below).
    • On Wednesday, 10/18, eighteen states filed a temporary restraining order to force the President to continue funding the CSR payments.


  1. Alexander-Murray Legislation: On Wednesday, 10/18, in response to the President’s decision to end the CSR payments, U.S. Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) reached a bipartisan compromise that is an important first step to stabilize health insurance markets and provide states more flexibility, while maintaining important patient protections.
    • They have proposed bi-partisan legislation, which will likely keep health insurance costs lower for consumers. This legislation is supported by nearly 30 cancer organizations representing patients, physicians, nurses, and social workers, because cancer patients and survivors need access to quality, affordable health insurance. However, there are some political compromises included in this bill.
    • This bill funds the CSR payments through 2019 and restores some of the funding that was previously cut by the President, for outreach and education about open enrollment and health insurance options.
    • This bill also takes some steps to expand access to catastrophic health insurance plans, which could allow more people to afford health insurance, but there is also serious concern about the limited coverage included in these plans. It also allows states flexibility to waive some of the ACA requirements for plans sold through the marketplace. Again, while it may expand access, there are some questions about the coverage included in those plans.
    • At this time, it is unclear if there are enough votes to pass this legislation. If you would like to share your opinion or experience, you can contact your U.S. Senators by calling: 844-257-6227.
  1. Executive Order: On Thursday, 10/12, the President also signed an Executive Order, which allows insurance companies to sell policies across state lines and to sell cheaper policies with less coverage than currently required under the ACA. The challenge with this proposal is that:
    • It allows insurance companies to avoid state health consumer protections.
    • It also creates a situation where people can buy minimal health insurance coverage, but if they are diagnosed with a serious medical condition like cancer, then they find out that those policies don’t cover needed medical care, like chemotherapy.
    • The Executive Order requires federal agencies to draft regulations, share the draft for public comments, and then release final regulations on these changes.

As these events unfold, Triage Cancer will continue to provide updates on these changes and how they may have an impact on the cancer community. Stay tuned.

Balance Billing: What You Need to Know

In order to avoid unexpected medical bills, it is important to know how your health plan Balance Billingworks and how a practice referred to “balance billing” can affect you. Most plans have a specific network of doctors and facilities that their members can use for their medical care. To be a part of a plan’s network, these doctors and facilities contract with the plan and agree to accept a specific rate for their services under the plan. These doctors and facilities are considered “in-network.” Doctors and facilities that don’t have a contracted relationship with an insurer are considered “out-of-network.”

The main difference between in-network and out-of-network healthcare providers is that in-network healthcare providers work with your insurance company to provide negotiated (discounted) rates, while out-of-network providers do not agree to discounted rates. For example:

You visit an in-network doctor and the total charge is $250. The doctor and your plan have negotiated a $75 discount. The plan then pays the doctor $140 (which they have agreed is the “allowed amount” for the doctor to receive). You then have to pay the remaining $35.

But, if you visit an out-of-network doctor and the total charge is $250 and there is no negotiated discount. The plan pays the doctor $140, but you’ll be responsible for the entire remainder, which is $110.

The latter part of the example regarding out-of-network doctors is an example of “balance billing.” Balance billing occurs when out-of-network doctors and facilities bill patients for the difference between a billed charge and a health plan’s allowed amount. However, this type of balance billing is typically not allowed when:

  • you have Medicare and you’re using a healthcare provider that accepts Medicare assignment;
  • you have Medicaid and your provider has an agreement with Medicaid; or
  • your doctor or facility has a contract with your health plan (in-network) and is billing you more than your plan’s contract allows.

Patients can also face balance billing when they receive care from a provider they did not know was out-of-network. For example:

You are going to have surgery at a hospital.  Both your surgeon and the hospital are in your plan’s network.  But during the surgery you need anesthesia so that you are not awake. The person who gives you the anesthesia, the anesthesiologist, whom you did not choose, is not in-network. A few weeks later you receive a large bill from the anesthesiologist, who was not covered by your plan. 

This is another example of balance billing, or “surprise billing.” Patients who think that they are being careful to only visit in-network providers are often surprised by these bills. Another example of when this often happens is when your doctor sends your blood to an out-of-network lab for testing. You can avoid this by asking your doctor to make sure they are using an in-network lab for your plan.

These situations can leave patients with huge medical bills that they are unable to pay, and can even lead to bankruptcy.

Some states have tried to protect patients from balance billing. For example, on July 1, a California law went into effect that says, if you have a non-emergency service and visit an in-network facility (like a hospital or a lab), you will only be responsible for your in-network share of the cost even if you’re seen by an out-of-network provider.

This is a giant step in terms of healthcare and patient care, as a recent Consumers Union survey found that nearly 1 in 4 Californians who visited a hospital or had surgery in the past two years were charged an out-of-network cost when they thought the provider was in-network.

In addition to knowing how to use your plan, you also need to make sure that you understand what type of plan you have. Because, the California law does not cover employer-sponsored plans that are self-insured. To find out of your plan in self-insured, you can call the number on your insurance card, or talk to your employer’s human resources representative.

New York and Florida also have comprehensive state laws to protect patients from balance billing. But there are a total of 21 states that have laws that deal with balance billing. To check if your state has a law protecting you from balance billing, visit Triage Cancer’s Chart of State Laws.

If you think you are being balance billed, there may be steps that you can take to deal with the bill.

Graham-Cassidy Fails, But Health Care Protections Still at Risk

Last week a new version of an ACA ‘Repeal and Replace’ bill was unveiled in the U.S. Senate. This legislation has been dubbed “Graham-Cassidy” after the two main authors of the bill, Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.). In order for the bill to be passed under a process called Budget Reconciliation, the vote must occur before September 30, 2017.  The reason that Republicans are trying to advance the legislation through the reconciliation process is that debate time is limited, it cannot be blocked by a filibuster, and therefore, the legislation only needs 50 votes to pass. There are currently 52 Republican Senators. The Congressional Budget Office has only released a preliminary review of the potential impact of the bill, and found that millions of people would lose health insurance coverage under this bill.

Unfortunately, like previous proposals this bill would also take away consumer protections and ultimately leave people with pre-existing conditions unprotected. (read more about earlier proposals).

Triage Cancer is proud to stand with patient advocacy groups from across the country in opposition to the Graham-Cassidy bill.

Graham-Cassidy Fails

Also, in case you missed it, Triage Cancer’s CEO, Joanna Morales wrote an open letter to Alaska Senator Lisa Murkowski explaining why we at Triage Cancer, a non-partisan organization, are so concerned about any effort to limit access to health care coverage. Her letter was featured in the National Coalition for Cancer Survivorship’s blog.

In light of the fact that Senators John McCain (R-AZ), Rand Paul (R-KY) and Susan Collins (R-ME) have publicly stated that they would not support the Graham-Cassidy bill, Senate leadership has decided not to bring the bill for a vote this week. Today, President Trump announced that he now has the votes to pass the bill and will bring it up again during the next reconciliation period. That time period is unknown because the Senate would have to pass a new budget resolution that established a new reconciliation period.

While the ACA is still law of the land, there are still some challenges with respect to access to health care:

  1. Insurers still face uncertainty over the status of the subsidy payments
  2. The 2018 open enrollment period has been significantly cut to a total of six weeks (November 1 – December 15, 2017). But, note that some states have chosen longer enrollment periods:
  • California – November 1 to January 31
  • Colorado – November 1 to January 12
  • D.C. – November 1 to January 31
  • Massachusetts – November 1 to January 31
  • Minnesota – November 1 to January 14
  • Washington – November 1 to January 1
  1. The Administration has cut funding for marketing and in-person assistors to help people enroll in coverage by 90%
  2. The Administration is impeding states’ ability to stabilize their health insurance marketplaces

Stay tuned for updates and follow us on Facebook and Twitter for late breaking news.

A Snapshot of the Impact of Proposed Health Care Changes

Health care is a daily news topic. With Republican Members of Congress and the Health Care ChangesPresident working to repeal and replace the Affordable Care Act (ACA), many aspects of health care have been brought into question recently, for example, what constitutes as a pre-existing condition, increased coverage for veterans, and who is covered by Medicaid, among others. Today we will provide a snapshot of the impact of the proposed health care changes.

Pre-Existing Conditions

A pre-existing condition is considered a medical condition that started before a person’s health insurance coverage began. Before 2014, when the ACA’s pre-existing condition consumer protections went into effect, some insurance companies would not only deny coverage to people with pre-existing conditions, but even if you were able to get a policy, that policy might not cover your pre-existing condition for a specific period of time, or at all.

The various Republican plans to repeal and replace the Affordable Care Act (ACA) have not done enough to retain protections for people with pre-existing conditions, which could increase health care costs and potentially limit coverage for an estimated 130 million Americans. And this is a very low estimate, when you consider that an insurance company can designate anything from acne, to allergies, to high blood pressure, to obesity, as a pre-existing medical condition.  If you think that broadly, most people in the U.S. have some sort of pre-existing condition.

Coverage for Veterans

Under the Affordable Care Act, coverage for veterans has improved greatly. According to the Urban Institute, the expansion of Medicaid to adults with incomes up to 138% of the federal poverty level (FPL) in more than half the states and the establishment of health insurance marketplaces with income-based financial assistance subsidies, expanded the health insurance options available to veterans.” In just the first two years after these ACA coverage options become available, the uninsured rate of nonelderly veterans dropped about 40%.

If these veterans lose these ACA options for coverage, writes, “This would likely leave the thousands who do not qualify for VA care without coverage at all, as insurance becomes unaffordable without the ACA’s subsidies. Hundreds of thousands of spouses and children could also lose coverage.”

Who is Covered By Medicaid

The latest Congressional proposal to reform our health care system (BCRA) would make severe cuts to the Medicaid program, potentially leaving millions without health insurance coverage. Who gets Medicaid now? Many groups in our society who need the greatest protection, including seniors, individuals with very low income levels, people with disabilities, and children. Many states have very high numbers of children covered by Medicaid.  For example, in North Carolina, nearly 96% of children have health insurance.  A little under half of those children have Medicaid.

Stay tuned to our blog for the latest information about changes to our health care system and other cancer survivorship issues.

ACA “Skinny Bill” Repeal Failed

Last night the Senate voted against the so called ACA “Skinny-Bill” Repeal, 49-51.  This Skinny Bill Failsbill would have eliminated the medical device tax as well as the individual and employer mandates.

Practically speaking, this means that the protections and health insurance options created by the ACA remain, for now.

Thank you to all of you who contacted your elected officials and used your voice to advocate for the cancer community.

However, our work is not done.

Many Senators have expressed their concerns with how the ACA repeal efforts were handled in secret and without open committee hearings to discuss proposals to improve our healthcare system. We hope that can be seen as a signal for Congress to start working together to make changes where the ACA can be improved upon.

Unfortunately, after the vote the President has declared via Twitter: “let ObamaCare implode.”

Unfortunately, we just don’t know what that means.  It could mean that all federal agencies simply stop enforcing the consumer protections created in the law. It may also mean that the Department of Health and Human Services will stop paying for Americans to receive financial assistance to purchase health insurance.

Senate leadership has indicated that they plan to move on to other legislative priorities. So the possibilities now for health care reform include: bipartisan committee work (e.g., hearings, debate, new proposals, etc.), stabilizing the marketplaces, and administrative action by federal agencies to change the health care law.  However, these actions may end up being contrary to each other, as many threatened agency actions have actually helped to destabilize the marketplace and increase premiums.

One thing does seem certain, the efforts to provide accessible, affordable health care for all Americans must continue. If this is an issue that concerns you, you can keep talking to your elected officials about how important access to quality, affordable health insurance coverage is to the cancer community.

We will continue to provide updates on this issue and others impacting the cancer community.

Health Care Update: Senate This Week

Here is a quick update on what has happened in the Senate this week to make changes to our health care system.

  1. The Senate attempted to vote on an amendment that included the last version of the Better Care Reconciliation Act (BCRA), and $100 billion for Medicaid, which moderate Republicans wanted and a proposal from conservative Republican Senator Ted Cruz (TX), to allow bare-bones health insurance plans to be sold again. Result: Did not pass with a 43-57 vote
  1. The Senate then voted on an amendment to repeal the Affordable Care Act, without any replacement, but the repeal would not go into effect for two years. Result: Did not pass with a 45-55 vote

Next steps:

The Senate is now considering other amendments to see if they can get 50 Senators to agree on something, so that the Senate can send the bill back to the House to finalize legislation for the President to sign.

These amendments are being referred to as a “skinny repeal,” which means that they are looking at specific provisions in the ACA that they can repeal.  Provisions that they are discussion include removing all taxes created by the ACA, and eliminating the employer and individual mandates.

The Congressional Budget Office has said that the skinny repeal would cause premiums to increase by 20% and 16 million more people would be uninsured, almost immediately. Experts say that the skinny repeal would destabilize the individual insurance market.

There will continue to be votes throughout the week, so stay tuned and continue to contact your elected officials.

Senate This Week

Senate’s Efforts to ‘Repeal & Replace’ Stall…For Now

This week the Senate’s efforts to repeal and replace the Affordable Care Act (ACA) Time For Plan Bhave stalled, for now. Yesterday, Senate Majority Leader Mitch McConnell said that he was not going to move forward with a vote on the Senate’s health care reform proposal called the Better Care Reconciliation Act (BCRA). This announcement came after two more (for a total of four) Republican Senators publicly declared that they would not support the bill. The four Senators are: Rand Paul (KY), Susan Collins (ME), Jerry Moran (KS), and Mike Lee (UT).

In response, McConnell suggested that the Senate would instead vote on a “repeal only” version of a bill to dismantle the ACA and that they would deal with replacing it later. They would give themselves two years to “deal with it,” as the repeal would not take effect for two years, which would also be after the next midterm election.

A true “repeal” of the ACA means that it would be like the ACA never existed, including the elimination of all of the ACA’s consumer protections, Medicaid expansion, some Medicare benefits, individual and employer mandates, and taxes. A similar bill was passed in 2015, but President Obama vetoed it.  That bill was scored by the Congressional Budget Office in 2015, and it found that between 30 and 32 million people would lose access to health insurance coverage.

However, just hours after this decision to move forward with a repeal vote was announced, three Republican Senators (Shelley Moore Capito (WV), Susan Collins (ME) and Lisa Murkowski (AK)) said they would not vote for a bill that would irresponsibly take away coverage from millions of Americans, with no alternative.  Their opposition to a repeal vote with no alternative means that it would be unlikely to pass if all Senate Democrats opposed the bill as well.

The President has also announced his support for a full repeal vote, suggesting that he will just “let Obamacare fail.” Unfortunately, we just don’t know what that means.  It could mean that all federal agencies simply stop enforcing the consumer protections created in the law. It may also mean that the Department of Health and Human Services will stop paying for Americans to receive financial assistance to purchase health insurance.

After a meeting at the White House today, Leader McConnell has declared that he will call for a procedural vote to allow Senators to debate and offer amendments on the BCRA.  Without further negotiating it is likely that the Senate will have to go back to the drawing board and come up with other proposals. Many have suggested that the Senate should go back to holding open hearings on these issues and to work together, in bipartisan efforts to improve our health care system. We will have to wait and see.  Unfortunately, we are now only 3.5 months away from the start of open enrollment for 2018, and there is so much uncertainty.

One thing does seem certain, the efforts to provide accessible, affordable health care for all Americans must continue. If this is an issue that concerns you, you can keep talking to your elected officials about how important access to quality, affordable health insurance coverage is to the cancer community.

Do You Need Health Insurance Now?

If you do not have health insurance coverage, you can apply for Medicaid at any time if eligible, or buy a policy through the State Health Insurance Marketplaces if you qualify for a special enrollment period.

  • For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar.
  • If you aren’t sure what your health insurance options are or want to understand more about health insurance, visit

Stay tuned to our blog, as we will continue to share ongoing developments in efforts to change our health care system.

Senate Health Care Proposal – Take 2 

Yesterday, the U.S. Senate released its revised proposal to overhaul health insurance in Senate Health Care ProposalAmerica.  Unfortunately, this new version of the Better Care Reconciliation Act (BCRA-2) would still cause significant harm to the cancer community.

For clarity, here we will focus just on the changes to the Republican proposal that we will refer to as BCRA-2.  Read more about the first version of BCRA.

The major provisions to take note of in this new version include:

  1. Cutting the Medicaid program so significantly that 15 million fewer people would have coverage, according to the Congressional Budget Office.
  2. Allowing insurers to sell plans with bare-bones coverage (“junk insurance”), as long as they also sell at least one policy that meets the ACA’s requirements. The concern is that by allowing individuals to purchase this less adequate, but cheaper coverage, healthier people would gravitate towards these plans, and people with pre-existing conditions would stay in marketplace plans, which would result in an unbalanced risk pool, and higher premiums for people buying marketplace plans. In addition, it would lead to higher medical debt for individuals buying junk insurance if they need medical care and find out that they only have bare-bones coverage. This was exactly a problem that the ACA was trying to address by creating minimum standards of coverage for plans being sold.
  3. Allocating $45 billion to deal with opioid abuse, a clear concession to two Republican Senators’ request.
  4. Adding $70 billion to help states stabilize their insurance marketplace.
  5. Keeping an ACA provision that places a 3.8% net tax on investment income and a 0.9% payroll tax on individuals making more than $200,000 annually.

While the BCRA-2 does contain some minimal improvements from the Senate’s original version, it ads changes that would be more harmful to the cancer community and others with pre-existing medical conditions. And, the overall impact of this proposal is still detrimental to most Americans.

Next Steps

In order for the bill to pass the Senate, the Republican Leadership need 51 votes in support.  There are 52 Republican Senators and 48 Democratic and Independent Senators. If there is a 50-50 tie, the tie can be broken by a vote from the Vice President of the United States, who is a Republican.

Moderate Senator Susan Collins (R-ME), has announced she wouldn’t support a procedural motion to allow debate on the bill. Conservative Senator Rand Paul (R-KY) also is unlikely to support the bill due to the fact that it doesn’t completely repeal the ACA. Therefore, Republicans can only afford to lose one more vote, if they want to pass the BCRA-2. Three other moderate Republicans have expressed serious concerns about this legislation: Dean Heller (R-NV), Shelley Moore Capito (R-WV), and Rob Portman (R-OH).  Senate Majority Leader Mitch McConnell has indicated that he wants a vote on BCRA as early as next week.

Do You Need Health Insurance Now?

If you do not have health insurance coverage, you can apply for Medicaid at any time or purchase a policy through the State Health Insurance Marketplaces if you qualify for a special enrollment period.

  • For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar.
  • If you aren’t sure what your health insurance options are or want to understand more about health insurance, visit

 What You Can Do

  • Contact your U.S. Senators and share your health care concerns, by calling (844) 257-6227. Even if you’ve called before, please call again. Even if you know how your Senators will vote, please call to share your thoughts.
  • To find your elected officials or learn more about becoming an advocate, visit our Advocacy resource page. You can also find the Facebook and Twitter handles for the current members of Congress here.

 Stay tuned to our Blog and sign up for our newsletter, as we will continue to provide updates as more information becomes available, about this issue that affects all of us.