Leukemia or lymphoma patients could face tough limits on the kind of care they can get through the public exchanges.
Bruce Pyenson, a consulting actuary at Milliman, and Jane Suh, an actuarial assistant at the firm, look at how individual private “qualified health plans” in California, Florida, New York and Texas cover blood cancers.
The analysts did the study partly to show how much QHPs can differ, even though the Patient Protection and Affordable Care Act requires the QHPs to cover a standardized “essential health benefits” package and includes several other coverage and underwriting rules.
“Many QHPs include only a limited number of National Cancer Institute-designated cancer centers or transplant centers in their networks,” the analysts write.
In some cases, narrow networks could keep patients with blood cancer from getting the kind of care their doctors normally would recommend, the analysts say.
The analysts also found wide variation in QHP “formularies,” or lists of covered drugs, for people with blood cancer.
Most of the formularies the analysts studied cover Thalomid, for example, but only a few cover Pomalyst.
Just getting information about what QHPs cover can be challenging, the analysts report.
“On a few insurers’ websites, it was not clear which network list or formulary list applied to exchange offerings,” the analysts write. “For some insurers, we relied on verbal instructions communicated to us by telephone.”