Health Care Reform

The Health Policy team monitors and responds to changes in the U.S. healthcare system. Read about our team’s work below to learn more about our efforts in the health care reform landscape. 

Affordable Care Act

The Affordable Care Act (ACA) is complex, ongoing, and affects coverage and insurance requirements for your patients now and into the future. It includes a large number of reforms to the health insurance and health care industry with the aim to increase access, improve quality, and control costs.

Learn about the major components of the ACA and how the legislation affects the patients you treat.

Overall Impact on HCT

  • Increased access through expanded coverage 
    More patients eligible for transplant should have coverage at the time of diagnosis. Affording transplant is almost impossible without health insurance coverage. The ACA increases access through expansion of coverage to young adults who wish to remain on their parents' insurance, Medicaid expansion (in some states) and increasing enrollment through Health Insurance Exchanges, which offer subsidies to help with premium costs.

  • Narrow networks could be a challenge for patients 
    In order to make exchange plans more affordable and competitive, insurers may reduce network size, limiting the number of in-network centers. 

  • Affordability is a concern   
    While exchange plans provide a means to more affordable insurance, some plans will leave your patients underinsured, with high out of pocket costs and limited coverage for transplant related costs, such as search, travel and lodging. 

  • ACA mandates differ by insurance type; never assume coverage
    There are different requirements and applicability of benefits based on the type of health insurance. Don’t make assumptions on patient benefits – always ask your patient’s payer specifically what is covered, what isn’t, if your facility is covered under the patient's plan, and any other rules or restrictions you should be aware of.

Major ACA components

Here is a summary of major components of the ACA and what they mean to HCT:

  • Individual mandate
    Requires most adults to have some sort of insurance coverage, or pay a tax penalty. Doing so spreads out risk across more young and healthy individuals in order to keep premiums low, which makes other reforms possible, such as no lifetime caps on coverage.

  • Health insurance exchanges and Medicaid expansion
    Allows more access to HCT and less delay in eligibility. However, Medicaid continues to provide limited transplant benefits, which are different in each state. Patients in a state without a transplant center may experience access issues. Learn more about Medicaid

  • External review of denied service
    If a claim or authorization is denied, an insurer must:
    • Explain the process for additional internal review
    • Give you the right to an external review and explain how to request it
    • Provide information on your state’s Consumer Assistance Program (if applicable). Learn about the appeals process.

  • Essential health benefits (EHB)
    The ACA requires coverage of many high-level care categories; components of HCT are covered in the categories.

  • No lifetime caps on coverage
    This applies to essential health benefits (EHBs). Annual Limits can be applied to non-EHB benefits, and grandfathered plans.

  • Eliminated pre-existing conditions exclusion
    Beneficial for former transplant recipients and donors who faced issues when purchasing individual policies in the past.

  • Coverage for clinical trials
    The ACA requires payers to cover routine costs of approved clinical trials for the treatment of cancer or other life-threatening diseases. This is good news as many transplants in the United States are performed as clinical trials. Learn more about clinical trials.

  • Expanded coverage for dependents and children up to age 26
    Beneficial for adolescent and young adult (AYA) transplant patients who in the past, faced issues trying to secure coverage once they turned 18 or when moving off of a parental plan.

Learn More About the ACA