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For cancer patients, or anyone with a chronic disease, one of the most valuable elements of the Affordable Care Act (ACA) is that you cannot be denied health insurance based on a pre-existing condition. Unfortunately, some health plans appeared to negate this protection by offering “adverse tiering” as a plan component. What this means is particular drugs used to treat a specific condition are likely to have an extremely high co-pay or co-insurance requirement. For example, cancer and HIV drugs were most likely to be placed with high co-pays that are costly and out of reach for most Americans. What this comes down to is someone with cancer could buy health insurance without issue, but if they choose a plan with adverse tiering, they may not be able to afford the drugs used to treat their condition.

Not only was this practice bad for patients, it was unfair to health insurance companies that provided reasonable coverage for both their plan and prescription drugs. The plans that engaged in adverse tiering could offer much lower premiums because ultimately they saved money through high co-pays or by not providing the benefit at all. This was unfair competition as the amount of monthly premium is what most consumers go on when selecting insurance coverage. But not all insurance coverage plans are created equally and selecting the wrong plan for your needs could be financially detrimental. Section 1302 of the ACA prohibits discrimination but was weak and left loopholes; it appeared to allow exemptions for high cost drugs. Additionally, any insurance company that used the adverse tiering structure was only required to provide the Department of Health and Human Services (HHS) a written explanation and then they could proceed with allowing it as a part of their proposed plan.

After a five year wait, last month HHS proposed a rule to fix this problem and fully implement the non-discrimination provision of the ACA. The proposed Rule 1557 prohibits discrimination “on the basis of race, color, national origin, sex, age and disability.” Under the Americans with Disabilities Act, conditions like cancer are defined as a disability and therefore would be protected. Rule 1557 also allows patients to take legal action if they are discriminated against, something far more likely to discourage any unscrupulous plans from adverse tiering as compared to only having to write an explanation to HHS.

The Colon Cancer Alliance will be providing comments to HHS in support of Rule 1557. We encourage you to respond or comment as well—public comments can be submitted here until November 9.

Don’t forget, the Colon Cancer Alliance serves as a source of information about colon health. If you have additional questions about colon cancer screening or are in need of support, please contact our free Helpline at (877) 422-2030.


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