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!

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:


What do donuts have to do with Medicare?

Before the Affordable Care Act, people with Medicare Part D coverage, often fell into a coverage gap, where they would have to pay thousands of dollars out of their own pocket to get the prescriptions drugs they need.

A standard Medicare Part D plan works like this, in 2014:

  • You pay a $310 deductible, meaning that you pay for the first $310 of your prescription drug costs
  • Then Medicare pays 75% of your prescription drugs costs and you pay 25%, until you reach $2,850 in out-of-pocket costs
  • Then you fall into the donut hole, until you reach $4,550 in total out-of-pocket costs
  • After that, Medicare kicks back in and pays 95% of your prescription drug costs and you pay 5%

This coverage gap is known as the “donut hole.” Far from the doughy, sugary-ball of goodness we all remember from days of frequenting the neighborhood donut shop, this deep-fried metaphor is forcing seniors and people with disabilities with Medicare to pay astronomical prices out of pocket for their medications. As a result of the ACA, this gap is closing, making prescription drugs more affordable, and improving care.

How much have people on Medicare saved?

According to the U.S. Department of Health and Human Services, more than 8.2 million people have saved over $11.5 billion on prescription drugs since 2010, for an average of $1,407 per person.

So, the question remains, when and how will the donut hole close?

  • In 2010, anyone with a Medicare Part D plan who reached the donut hole received a $250 rebate.
  • In 2011, people who were stuck in the donut hole began receiving discounts on covered brand-name drugs and generic drugs.
  • In 2014, Medicare will cover 52.5% of brand name drugs and 72% of generic drugs while people are in the donut hole.
  • All and all, Medicare Part D coverage will gradually increase between now and 2020, when (much to the dismay of those who cling to the nostalgic memory of the doughy, sugar-coated ball of goodness) the donut hole will be closed entirely. (see the chart below)

DH Chart

As we approach open enrollment periods, the Affordable Care Act is helping more people get the medication they need, when they need it, without breaking the bank. But don’t worry; the donut shop is still on the corner.

For state-by-state information on discounts in the donut hole, please visit:

For more information about Medicare prescription drug benefits, please visit:

Prescription Drug Coverage: Do You Understand Yours?

Imagine choosing a health insurance plan, through your employer, the Health Insurance Marketplace, or even directly from an insurance company.  You pay your monthly premium and then you go to the pharmacy to fill your very expensive prescription, only to be told that your insurance doesn’t cover the prescription that your doctor gave you.

Now what?

  • Pay for the prescription out of pocket?
  • Don’t fill the prescription?
  • Go back to your doctor and ask if there is another drug you can take that is covered? (what if the answer is no)
  • Change your insurance plan? (wait – you can’t do that until open enrollment or until you qualify for a special enrollment period)

How can we avoid a situation like this?  We can’t.

Not unless we have access to clear, understandable information on what drugs are covered by each health plan (formulary = list of drugs covered) and at what level of coverage (tiers = different levels of formulary coverage).

Plans sold on the federal Health Insurance Marketplace ( provide this information now.  When you look at your plan options, you can actually click a link to see the plans formulary and check to see if your drugs are coverage.  You can also see a list of providers who are covered.

Rx Chart

Most state-run Health Insurance Marketplaces don’t provide this information.  And this gap in information has a serious impact on the cancer community.

California currently has a bill waiting for the Governor’s signature (SB1052) to try to address this issue in California, by requiring the:

  • State Marketplace (Covered California) to create a search tool, to allow consumers to search for plans that cover specific prescriptions drugs
  • plans to provide a complete formulary on their website and keep it up to date
  • plans to explain your out of pocket costs for prescription drugs
  • plans to explain if certain prescription drugs have restrictions, like requiring a pre-authorization before you can get access to a drug

For more information, about using your prescription drug coverage, visit:

For more information about SB1052, visit: or click here.

Workplace Wellness and the Affordable Care Act

wellnessWorkplace wellness programs are created to support healthy behavior in the workplace, which can improve employees’ health and lower the cost of health care spending.  A majority of workplace wellness programs focus on prevention of chronic diseases, although workplace wellness programs address a variety of conditions.  In a report by RAND and sponsored by the U.S. Department of Labor and the U.S. Department of Health and Human Services, the most frequently target of workplace wellness programs is diabetes with 85% of the programs focusing on it.  Another half of employers with wellness programs address other conditions such as asthma, COPD, cardiac disorders, depression and cancer.

The scope of what workplace wellness programs offer varies.  Wellness programs can include individual health coaching, health lectures, webinars, fairs providing screening and educations.  Screenings, such as cancer screenings, can be key to early detection.

The Affordable Care Act (ACA) has created incentives to encourage employers to implement or keep existing wellness programs.  New rules under the ACA outline standards for workplace wellness programs, including rewards for employees meeting health goals.  Under these new rules, wellness programs cannot be overly burdensome to the employee and there must be reasonable alternatives for employees with medical conditions that would make it difficult to reach a common standard.

Under the new rules, employers can also reduce the amount they charge employees for coverage who participate in a workplace wellness program up to 30% of the cost of health coverage.  This is up from 20% before the ACA.

The new incentives under the ACA make it easier for employers to implement workplace wellness programs, which can help slow the progression of chronic disease, provide screenings that lead to early detection, lower the costs of healthcare and pass savings onto employees.

To read more about the RAND report on workplace wellness programs, click here.

To read more about the Affordable Care Act’s role in workplace wellness programs, click here.

“Essential Health Benefits” and a Birthday!

The Patient Protection & Affordable Care Act (ACA) is celebrating its fourth birthday today! Cupcake

Over the last four years, the ACA has made a number of changes to our health care system that have had an impact on the cancer community.

One of those changes was the new requirement that most health plans, whether they are offered inside or outside of the State Health Insurance Marketplaces, must cover “essential health benefits.”

Both small-group health plans that cover employers with less than 50 employees and non-grandfathered individual health plans are covered by the requirement.  Non-grandfathered health plans are plans that did not exist before March 23, 2010, when the ACA was signed into law.   In states where Medicaid is expanding, these programs must also offer coverage for essential health benefits to those who are newly eligible for Medicaid.

There are ten categories of essential health benefits that plans must cover:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventative and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

Along with coverage of essential health benefits, the ACA also allows people to get health insurance coverage regardless of their age, gender, or medical condition and prohibits insurance companies from charging people higher premiums because of their medical condition or health history.

If you do not have health insurance, or are losing your coverage this month, be sure to apply for health insurance through your State Health Insurance Marketplace before the deadline on March 31, 2014!

Get information on your State Marketplace, or visit to learn more about these health care benefits, as well as compare plans and find the one that fits your lifestyle and budget.

“Lawfully Present”. . .“Permanent Resident”. . .“Deferred Action”. . . Oh my!

These are all terms related to an individual’s immigration status in the United States.Immigration Stamps

Do you fit into one of these categories?  Trying to help someone who might?  Not sure?

Depending on your immigration status, you may be eligible for health insurance benefits under the Affordable Care Act (a.k.a. health care reform or ObamaCare).

Here are some excellent resources from the National Immigration Law Center (NILC) to help you figure out whether or not you, or someone you know, might be eligible:

Here is additional information about: Medical Assistance Programs for Immigrants in various States.

For more information about visas, visit:

For more information about green cards, visit:

For general information about immigration in the United States, visit:

Disclaimer not your only option


Do you want to sign up for health insurance, but are frustrated by  We understand!  The good news is that while the website is being worked on, applying for health insurance online isn’t the only option for you.  You can also apply via mail, over the phone (800-318-2596), or in person.

Also, If you are in one of the states below, you can go directly to your State’s Health Insurance Marketplace to find information on your health insurance options, qualify for financial assistance, and sign up for a plan!






NYNew MexicoRhode IslandMarylandMADC



























Triage the Unexpected: Young Adults See Value in Health Insurance!

KFF AYA Health Insurance Chartby Katie Pausic, Triage Cancer Intern

With the ongoing implementation of the Affordable Care Act, the Kaiser Health Tracking Poll looked to see how young adults, the uninsured, and those with pre-existing medical conditions react towards health care reforms. The poll found  that health insurance is valued among the majority of Americans; with 87% saying that insurance is “very important,” and 88% of Americans reporting that insurance is “something [they] need.”


A main focus of the ACA is to expand health insurance to more people in the United States, and one specific group that the ACA wants to reach is young adults.  The Kaiser Health Tracking Poll found that more than seven in ten young adults believe that having health insurance is “very important” and feel that it is worth the expense.  This is surprising considering that many believed that young adults would be the most resistant to the ACA.  When it comes to health care, the biggest fear among young adults is that they will not be able to afford their medical bills if they found out they had a serious illness or if they were involved in a serious accident.

Another group that this poll focuses on is the uninsured.  Like young adults, the majority of those who are uninsured also believe that it is “very important” to have health insurance. The biggest obstacle that the uninsured come up against when it comes to insurance is the cost to have it.  Four out of ten uninsured individuals said that health insurance is too expensive, and that is why they are not insured.  Also, those who are uninsured are twice as likely to be concerned about not being able to pay for both routine and catastrophic medical bills.

Individuals with pre-existing conditions will also be affected by the ACA in 2014.  Many of those with pre-existing conditions have had trouble obtaining and keeping health insurance, but under the ACA, those with pre-existing conditions cannot be denied coverage.

The Kaiser Health June Tracking Poll also found out that “unfavorable views of the law still outnumber favorable ones,” with 43% against the ACA and 35% in favor.  It is noteworthy that those who have unfavorable views toward the ACA do because it does not “go far enough to change the health insurance and health care system.”

Even though 40% of Americans do not believe the ACA will have much impact on their own families, the majority do see how the law will benefit the uninsured and those with pre-existing conditions.  The new provisions in the ACA will be significantly helpful to the cancer community. Due to the new “guaranteed issue” provision, those who have cancer or who have had cancer in the past cannot be denied health insurance coverage AND they cannot be charged more because of their health status or health history.  In addition, young adults can now stay on their parent’s insurance until the age of 26, no matter if they have a pre-existing condition, are a full-time student, or a dependent under IRS standards. With the new provisions of the ACA going into effect in 2014, many individuals and families will finally have access to healthcare.

Health Care Reforms are Moving Along at the State Level

CoveredCalifornia1Our health care system is undergoing significant changes over the next four months and into next year.

On October 1, 2013, individuals and small business with fewer than 50 full-time employee equivalents will have the option to buy health insurance coverage through the state health insurance marketplaces. Marketplaces will be available in every state, but some states will run their own marketplace, some states will have marketplaces run by the U.S. Department of Health & Human Services (HHS), and some states will partner with HHS to run their marketplace.

To learn more about the marketplaces and your state-specific information, visit  Our website also has state-specific information that can be found here.

Breaking News . . .

Just last week, California’s exchange released information about the 13 plans that will initially be available to people throughout the state.  For more information, visit or click here to view the plan booklet.

Also this week, Illinois’s legislature passed a bill to expand Medicaid to individuals who are at or below 138% of the federal poverty level ($15,856 in 2013).  Governor Quinn is expected to sign this bill soon.

As you can see things are changing on a daily basis so please check back for more updates!