How States are Changing Health Insurance Rules

In an ongoing effort to keep you up to date on the many proposed and approvedhealth insurance
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.

National News:

Two weeks ago, we reported that 11 states have applied for waivers to make some individuals work, in order to get access to health care through Medicaid. Since then, Kentucky and Indiana’s waivers have already been approved by the Center for Medicare and Medicaid Services and those states are moving forward with implementing plans for a Medicaid work requirement. Click here to learn more about the impact of the Medicaid waivers and to see what the states are asking for in their waivers.

In addition to work requirements, five states have also asked the U.S. Department of Health & Human Services if they can place a lifetime cap on how long an individual can receive Medicaid coverage. For example, Arizona, would like to place a 5-year lifetime cap on coverage. Kansas, Utah, Maine and Wisconsin are also seeking to impose lifetime caps.

This would be a substantial change to the Medicaid program, since signed into law under President Truman in 1965.  More than 68 million people receive Medicaid coverage, including children, seniors, and people with disabilities.  HHS has not released any guidance on this issue, to date.


Ohio has now joined Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, Mississippi (still in process), New Hampshire, North Carolina, Utah, and Wisconsin, in asking for permission to add a work requirement to their Medicaid program. The work requirement would begin July 1, 2018, if approved in time.

Ohio has also asked the federal government for permission to not comply with the individual mandate. This will likely have no actual impact, as Congress reduced the penalty for not purchasing health insurance to $0, in the latest tax bill. The $0 penalty will begin in 2019, which means that those who don’t have health insurance in 2018 will still be responsible for the penalty!

Rhode Island:

Rhode Island is also making cuts to its Medicaid program, which covers more than 300,000 people. Individuals will be required to pay co-pays when receiving health care services or prescription drugs.  However, there will be an annual cap on co-pays equal to 6% of an individual’s income.


Idaho announced last week that they 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. Insurers argue that providing this quality coverage is more expensive and that is why plans sold in the Health Insurance Marketplace can be more expensive.

Idaho’s approach to bring down the cost of insurance is to allow plans to offer less coverage and to exclude people with pre-existing conditions. This directly violate the law. It will be up to HHS to enforce the law or allow Idaho to continue offering these illegal plans. There are many other states waiting to see how HHS will react.

Blue Cross of Idaho has already unveiled five new plans that don’t comply with the ACA, including having annual caps on coverage and pre-existing condition exclusions for up to 12 months.

Advocates have three concerns about this approach:

  1. People who are healthier will leave the Marketplace to buy these cheaper plans, which will drive up the costs of plans in the Marketplace
  2. If these healthier individuals are diagnosed with serious medical conditions, they will find they have inadequate coverage
  3. People with pre-existing conditions won’t be able to purchase these cheaper plans, which means they will be stuck in the marketplace with more expensive plans

This turn of events is very concerning for the cancer community, as it allows insurance companies to do an end run around the ACAs protections for people with pre-existing conditions.

Why Pre-Existing Condition Protections Are Not Enough

Over the last week, we have continued to hear about proposed changes to our health triage cancer blog pre-existing conditioncare system from the President-elect and members of Congress.  Some of those changes would have a significant impact on the cancer community. Next week, we will start to break down how those changes might impact the cancer community. However, this week, we wanted to talk about pre-existing conditions.

What is a Pre-Existing Condition?

“Pre-existing condition” used to be a term that only health insurance companies and health law attorneys used. The Patient Protection and Affordable Care Act (ACA) made that term more common, because the ACA prohibited health insurance companies from denying coverage to anyone with a pre-existing condition. A pre-existing condition is any medical condition that exists before the health insurance policy begins; the condition “pre-exists” the policy. A pre-existing condition is often thought of as a serious medical condition, such as a cancer diagnosis.  But prior to the ACA, insurance companies would routinely deny coverage to anyone with conditions such as arthritis, allergies, asthma, or even acne. Really, any medical condition was a reason for denial. And this had a huge impact on the cancer community. Over the close to two decades that we have worked in the cancer community before the passage of the ACA, we  would often have to to tell people that they didn’t have any option to access health insurance coverage because of their pre-existing condition.  The ACA changed that.

This change to our health care system was so significant that most people don’t want to see that portion of the ACA repealed. The President-elect and the Speaker of the House have both said that they would want to continue to provide protections for people with pre-existing conditions.  However, they have not provided details on whether they would do that by keeping the ACA rule, or create some other option.

Last week, we highlighted a few of the consumer protections in the ACA, some of which apply to plans offered by employers, plans offered through the State Health Insurance Marketplaces, and individual and family plans that you can buy directly from an insurance company.  Those consumer protections would be lost if the ACA were to be repealed.

Assuming that they keep the rule that ensures people with pre-existing conditions can purchase insurance, that rule by itself, isn’t enough to protect consumers, and here’s why:

  1. Coverage: the ACA ensures that plans have a minimum level of essential health benefits.
    1. Without this protection, people with pre-existing conditions might still be able to buy a plan, but the coverage might be minimal (like not covering mental health care or prescription drugs).
  2. Caps on benefits: the ACA does not allow insurance companies to place annual or lifetime caps on essential health benefits.
    1. Without this protection, people with pre-existing conditions might still be able to buy a plan, but the plan might cap benefits at $100,000 for the year, or $1 million for a lifetime, or even lower, leaving people to pay for medical expenses out of pocket.
  3. Rescissions: the ACA forbids health insurance companies from canceling your policy, unless your commit fraud on your application or leave off important information.
    1. Without this protection, people with pre-existing medical conditions might find their policies cancelled after submitting an expensive claim that the health insurance company doesn’t want to pay.
  4. Prevention: the ACA requires most health plans to provide free preventive care.
    1. Without this protection, we will go back to having to pay co-pays, co-insurance amounts, and deductibles when receiving preventive services, and many people will be forced to forgo that care.
  5. Out-of-pocket maximums: for plans sold in the Marketplaces, the ACA placed a cap on how high the out-of-pocket maximums could be, which greatly reduced out-of-pocket costs for people with pre-existing conditions.
    1. Without this protection, people will likely see even higher out-of-pocket medical costs.

And finally . . .

  1. Price: the ACA requires US Citizens, and those lawfully present in the US, to have health insurance coverage (with some exceptions).
    1. Without this requirement, many who are not currently in need of medical care, will not buy health insurance coverage, leaving only people with pre-existing conditions buying coverage. If we do not have a balanced risk pool, which includes people who are healthy as well as people with more serious medical conditions, then health plans will likely increase monthly premiums for everyone. In addition, if those people who are healthy wait until they get sick to buy coverage, that will further skew the risk pool and increase premiums even more. If the plans are too expensive to buy, then it won’t matter that people with pre-existing conditions are “allowed” to buy health insurance coverage.

We hope that our elected officials will keep these issues in mind as they make their decisions over the next few months on any changes to health care system.

What You Can Do

We will have to continue to wait and see what happens, but in the meantime, there is something that you can do.

  1. Share your experience and concerns: Call or email your elected officials and share your health insurance concerns. To find your elected officials or learn more about becoming an advocate, visit our Advocacy resources page. You can also find the Facebook and Twitter handles for the current members of Congress here.
  1. Tell your story: Share your story with Families USA or the National Coalition of Cancer Survivorship (NCCS), two health care advocacy organizations that are working to help our elected officials understand the dire consequences of repealing the ACA and how certain changes to our health care system can impact us all. But they need the stories of real people. If you feel comfortable doing so, you can share your story at or at

Do You Need Health Insurance Now?

We also want to remind you that change is Washington is rarely swift and that we may not see changes for most of 2017.  That means that we have to continue to operate with the system we have for now and ensure that people have health insurance coverage for 2017.  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 until January 31, 2017. If you want your policy to begin on January 1, 2017, you need to have picked a plan by December 15, 2016.

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, our recently released toolkit, Finances 101, may be useful.

Stay Tuned

Stay tuned to our Blog and sign up for our newsletter, as we will continue to provide updates as more information becomes available in the coming weeks and months.

Make the Most of Health Insurance Open Enrollment!

Open Enrollment for the Health Insurance Marketplace is now open!

Having a good health insurance plan can be a real life and wallet saver and as you may know it is also a requirement! The Open Enrollment period for 2016 health care coverage runs from November 1, 2015, to January 31, 2016. If you want your coverage to begin by January 1, 2016, you have to enroll or change your plan by December 15, 2015.

Triage Cancer - 4 Ways to Get Covered

The requirement to have health insurance coverage is often referred to as the Individual Mandate Penalty. This penalty almost doubles in 2016, for those who don’t have health insurance, to $695 per person or 2.5% of your household income, whichever amount is more.

Triage Cancer - Obamacare Open Enrollment Facts

Source: Obama Care Facts, 2015.

Even if you already have a health care plan that works for you, it is always good to compare different plans. Shopping around can’t hurt, even if you have health insurance coverage through your employer. Plans and pricing can change every year, so you may be able to find new coverage that is more affordable or better fits your needs.

Triage Cancer offers a free tool to you find health insurance options as well as information about other benefits you may be eligible for at the federal, state, and local levels.

By taking the time to compare your current plan with new options, you may find a cheaper plan or find out that you’re entitled to other benefits, like financial assistance. Based on where you live and your household income you may qualify for your state’s Medicaid program or a premium tax credit that lowers your out-of-pocket costs when you chose a health insurance plan from a private health insurance company.

5 key things to look for when choosing a health insurance plan:

  1. Monthly premium cost
  2. Deductible cost
  3. Out-of-pocket maximum cost
  4. Are my health care providers covered by the plan
  5. Are my prescription drugs covered by the plan

We know that these terms and choosing the right health insurance policy can be confusing, so to answer any questions you may have watch our latest FREE webinar recording that covers tips on how to choose a plan that works for you.

Progress has been made on increasing the number of people with health insurance. According to the US Census Bureau, in 2009, before the ACA was passed, about 15.7% of the population was uninsured. Recently, a study done by the CDC using 2015 Census data showed that the total uninsured rate has dropped to 9.2%. In California alone, 4.5 million new people enrolled in health care plans between 2013 and 2015. Even though these numbers are cause for excitement, there is still work to be done. If enrollment rates continue to increase, insured patients can look forward to their health needs being met, and less problems paying for health services than when they were uninsured.

There are so many benefits to selecting the perfect health care plan for you and your family, be sure to make the most of this year’s Open Enrollment and discover the plan that will best suit your needs. Triage Cancer will be posting valuable information about health insurance coverage throughout Open Enrollment.

Here are some other helpful tools:


  1. ObamaCare Enrollment Numbers. Accessed October 28, 2015.
  2. Insure the Uninsured Project Blog Post. Open Enrollment: Lessons from the Field; October 20, 2015. Accessed: October 28, 2015.
  3. Insure the Uninsured Project Blog Post. Summary of the Kaiser Family Foundation Survey of California’s Uninsured; August 11, 2015.

Do you qualify for Medicaid? It depends on where you live.

As a follow up to last week’s blog about the 50th birthday of Medicare and Medicaid, we 50th Medi Bdaywanted to share some additional resources on Medicaid.

This fact sheet explains the difference between Medicare and Medicaid:

The Centers for Medicare & Medicaid Services has also created a series of fact sheets for consumers to help people understand more about Medicaid.

Medicaid is the federal health insurance program that covers people who have low-incomes and meet certain categories of eligibility. Medicaid eligibility varies by state.

Some states expanded their Medicaid programs under the Affordable Care Act, and some did not. The fact sheets are specific to the state in which you live and are available in English and Spanish. Here are some examples:

For states expanding Medicaid:

For states who have not expanded Medicaid:

You can enroll in Medicaid at any time during the year and get coverage right away.

Nearly 70 million Americans receive health insurance coverage through Medicaid.

Retiree Health Insurance Plans

Has a neighbor told you that his daughter is still covered by his health insurance plan, even though his daughter is 24?

Wondering why you haven’t gotten any information that your son, who is 23, can?

Do you have a retiree-only health insurance plan?

If so, some of the recent consumer protections in the Patient Protection & Affordable Care Act (ACA) may not apply to you and your health plan.

These are all examples of ACA protections that do not apply to retiree-only plans:

For more information, visit:

And for those of you who like to get in the weeds, here is a handy chart with additional information about ACA provisions that don’t apply to specific types of health plans:

Breaking News: The ACA lives to fight another day

It’s a day filled with relief for the cancer community, as the U.S. Supreme Court has decided to uphold the Patient Protection & Affordable Care Act (ACA) one more time and protect the financial assistance that millions of people receive across the country to help them buy health insurance coverage.

The Supreme Court affirmed the 4th Circuit’s decision in King v. Burwell by a 6-3 ruling (with Scalia, Thomas, and Alito dissenting):

Chief Justice Roberts wrote, “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.  If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.  Section 36B can fairly be read consistent with what we see as Congress’s plan, and that’s the reading we adopt.”

The true irony of this decision, is that most people didn’t even realize that their access to affordable health insurance coverage had even been in jeopardy!

For background on the King v. Burwell case, see our earlier post this week.

As I sit here watching the news reports, they show video of a large crowd of people holding signs in front of the Supreme Court Building in Washington, D.C. Each sign has the name of the state and the number of people in that state who were going to lose access to the financial assistance to buy their health insurance: OH – 497,000; AZ – 266,000; PA – 414,000; UT – NE – 97,000; OK – 208,000; and so on. Millions stood to lose. Where you live shouldn’t determine whether you get access to affordable health insurance.

Having spent two decades helping people get and keep access to health insurance, I am certainly relieved that this option isn’t being taken away from a community that already struggles with access to affordable health care and who often need help the most.

In his statement today about the ruling President Obama said Americans can now be “secure in the knowledge that affordable, portable, health care will be there for us, and always will be. And if we get sick we won’t lose our homes, if we get sick we will still be able to look after our families. That is when America soars, when we look out for each other and take care of each other…when we strive to be better and to do better than the generations before us and build something better for the generations to come…so this was a good day for America. Now, let’s get back to work!”

It’s been five years and 3 months since the ACA was signed into law, and countless numbers of people in the cancer community have benefitted from the consumer protections and new access to health insurance coverage provided by the ACA.

The ACA is here to stay . . . at least for another day.

Now let’s get back to work.

For more information about the ACA, visit, download our Quick Guide to the ACA, and read our blog posts.

This Week: The Supreme Court May Make Your Health Insurance Too Expensive!

Do you have a health insurance plan that you bought from

If so, this blog is especially for you . . .

Source: Kaiser Family Foundation

Source: Kaiser Family Foundation

The cancer community is anxiously awaiting the U.S. Supreme Court’s decision on the King v. Burwell case, in which the plaintiff argues that individuals who buy health insurance from a “federally-facilitated” health insurance marketplace, should not be entitled to financial help to buy insurance plans.

The decision is expected to be announced on Thursday, June 25, or Monday, June 29. To read the oral arguments of the King v. Burwell case, which occurred in March, visit:

This case depends on how the 9 members of the Supreme Court look at one sentence in the Patient Protection and Affordable Care Act (ACA), which says that the financial assistance will be available for people “enrolled through an Exchange established by the State.”

Although, the ACA intended for every state to create their own state health insurance marketplace, aka exchanges, more than half of the states chose not to do so. This left the federal government to create marketplaces for those states.

This chart shows the type of marketplace in each state, for 2015:

State Marketplace Chart June 2015

If the Supreme Court agrees with the plaintiff in this case, then people who live in a state without a state marketplace will lose their financial help to buy health insurance.

It is estimated that 8.2 million people will lose their health insurance coverage, because they will not be able to afford their monthly premiums without the financial assistance provided by the ACA. In Florida, for example, 93% of people with a marketplace plan get financial assistance. Nationwide, 88% people with marketplace plans receive financial help, which on average, cuts the cost of monthly premiums by 72%.

With fewer people participating in the marketplaces, it will increase the premiums for everyone who continues to buy their coverage from the marketplaces. Some estimates suggest Alaska, Wyoming, Delaware, Wisconsin and South Carolina will be hardest hit.

For more details and research about the impact of a Supreme Court ruling for the plaintiff, visit:

For detailed, state-by-state information on the potential effects of the King v. Burwell ruling, visit:

As of now, there is no plan in place to deal with a Supreme Court decision eliminating the financial assistance. It’s unclear if that would mean that the financial assistance would end the minute the Supreme Court makes their decision, if it would end at the end of the month, or even at the end of the year.

Despite such an important decision looming, most people aren’t paying any attention to how this decision is going to impact their daily lives.

For more information about marketplaces in general read this blog post.

Stay tuned . . . We will post a blog update once we have a Supreme Court decision!

Latest updates on the ACA & Your Health Insurance Options

Buying & Renewing Health Insurance Coverage

Open enrollment to buy health insurance coverage through your State Health Insurance Marketplace closed on February 15, 2015.

However, many people are unaware that they will have to pay a penalty on their taxes if they do not have health insurance coverage. So, in order to help uninsured people avoid a penalty, will reopen again from March 15, 2015, to April 30, 2015 for those who learn that they will have to pay a penalty for not having coverage in 2014 and who want to buy coverage for 2015. This is only available in states where the federal government runs their State Marketplace.

In addition, a number of state run Marketplaces are extending the open enrollment period. Minnesota’s MNSure will offer a special enrollment period only for people who owe a penalty from March 1, 2015, to April 30, 2015. Vermont Health Connect is available through May 31 for those who have to pay a penalty, and Washingtonreopened sign-ups for this group from February 17, 2015 to April 17, 2015.

California also announced a special enrollment period from February 23, 2015, to April 30, 2015, for those who need to pay a penalty.New York will accept new enrollees for those subject to a penalty from March 1, 2015, to April 30, 2015.

Open enrollment for 2016 health insurance won’t open until this fall. Final dates have not been announced, so stay tuned!

ACA Case at the Supreme Court

Some of you may have heard that the Supreme Court is currently hearing a case about the ACA, called King v. Burwell. The case has been filed by some who believe that financial assistance to help people buy coverage should not be available to anyone who buys their coverage through their State Marketplace, if that Marketplace is currently being run by the federal government. If the Supreme Court agrees, then only people who live in states that run their own State Marketplaces will be eligible for financial assistance to buy health insurance coverage.

Only 14 states currently run their own State Health Insurance Marketplaces: CA, CO, CT, DC, HI, ID, KY, MA, MD, MN, NY, RI, VT, and WA.

A decision from the Supreme Court on this case is expected by June 2015.

Watch this video for more information:

For more information about health insurance, register for Triage Cancer’s free webinar on March 18, 2015.  Register here.

4 More Days Left to Enroll!

Do you need health insurance for next year? The open enrollment period has begun and if you want your coverage to begin on January 1, 2015 you must sign-up by Monday, December 15, 2014.

Confused on how to get started? The links below have all of the information you need to be covered for 2015!


If you are not able to afford a plan in the Marketplace and do not qualify for Medicaid or CHIP there are community centers that provide primary care, baby shots, and more. Find a community center near you that provides these health services here:

If you already have health insurance through the Marketplace, it is a good idea to review your current health care plan to make sure it still works for you. These five steps will walk you through how to review and make changes to your plan so that they will go into effect on January 1, 2015:

Want to receive email and text reminders so you will never miss a deadline? Register here:

For more information on the Affordable Care Act and this open enrollment period, listen to our webinar “Updates on the Affordable Care Act & Open Enrollment” by clicking here:

If you don’t need coverage starting January 1, 2015, then you have a little more time, as open enrollment will continue through February 15, 2015. After that date, the only way to be eligible for purchasing insurance in the Marketplace is if you qualify for a Special Enrollment Period after a life event (e.g., losing a job, moving to a new state, etc.).

Health Insurance & Open Enrollment: What You Need to Know

Man-on-a-PathWe know that health insurance can be overwhelming and stressful. But it doesn’t have to be. The Patient Protection and Affordable Care Act (ACA) includes changes to make it easier to shop for, and purchase, insurance.

As we approach the second open enrollment period (November 15, 2014, through February 15, 2015) to buy insurance coverage through the state Health Insurance Marketplaces created by the ACA, here are a few tips to help you navigate health insurance.

  1. Make sure you understand common health insurance terms. Don’t be embarrassed if you’ve heard these terms a lot, but still don’t totally understand them or how they all work together. Here are a few critical ones:
    • Premium: the amount you pay monthly just to have health insurance
    • Deductible: the amount you have to pay each year before the health insurance policy starts paying for your medical expenses
    • Co-Pay: an amount you may have to pay each time you access certain health care services (e.g., $25 when you see the doctor, or $10 for each prescription drug)
    • Cost-share: the difference between what your health insurance policy pays and what you pay for your medical expenses (e.g., 80/20 plans are ones where you are responsible for 20% of your health care costs and the plan is responsible for 80%, after you meet your deductible)
    • Out-of-Pocket Maximum: the most you are responsible for paying for covered medical care each year. The deductible plus any co-pays or cost-share amounts that you pay add up to help you reach out of pocket maximum. Once you reach that amount, your insurance should pay for 100% of your covered medical expenses.
  1. Keep an eye out for hidden costs as you shop for new insurance. For example, if you are in the midst of treatment, a Bronze level plan (60/40 cost share) is likely not going to be appropriate. And pay attention to whether or not plans have separate deductibles for medical services and prescription drugs.
  1. Learn about what is actually included in the ACA and how the law may potentially benefit you. One resource would be Triage Cancer’s Quick Guide to the ACA, available for free at:
  1. Look into possible financial assistance options available to you.
  1. Know that that there are places to go for more help when trying to navigate health insurance: