Access to Health Care

ACS CAN advocates for policies that provide access to treatments and services people with cancer need for their care - including those who may be newly diagnosed, in active treatment and cancer survivors.

Access to Health Care Resources:

ACS CAN provided comments on CMS' Draft 2016 Letter to Issuers in the Federally-facilitated Marketplaces, including comments related to network adequacy, provider directories, nondiscrimination provisions, and other issues.

ACS CAN provided comments on CMS' initiation of a national coverage analysis for cervical cancer screening with a combination of HPV and cytology (Pap) testing.

ACS CAN filed comments on the 2016 Notice of Benefit and Payment Parameters proposed rule, including comments related to Special Enrollment Periods, prescription drug benefits, nondiscrimination, cost-sharing requirements, network adequacy standards, and other issues.

ACS CAN commented on the Medicare CY2015 Physician Fee Schedule, in which we urged, among other things for CMS to designate screeming colonoscopioes that resule in polyp removal or biopsy as a preventive service.  We also commented on the proposed provisions related to the Chronic Care Management code.

ACS CAN, the American Heart Association, the American Diabetes Association released a joint statement in support of the Medicaid program, noting that any reforms should improve the value of care provided under the program and should not reduce access for Medicaid beneficiaries.

As the National Association of Insurance Commissioners (NAIC) updated its Managed care Plan Network Adequacy Model Act (Network Adequacy Model Act), ACS CAN filed comments urging the NAIC to adopt policies that would ensure that health plan networks are sufficient to provide enrollees with access to a sufficient number and type of providers (including oncology services) to meet the needs of the enrollees.

ACS CAN commented in the FY2015 Medicare Hospice payment rule, in which we urged, among other things, for Medicare to develop a workable solution to better clarify when a prescription drug is covered under the Hospice or Part D benefit.

For persons living with cancer, access to specialty practitioners is paramount. Millions of Americans are now choosing health coverage through the new insurance Marketplaces and these enrollees need to be able to easily determine whether specific physicians are in a plan’s network.

Adequate and sustained investments and improvements in the prevention and early detection of disease are essential to refocusing the health care system on wellness.

Prescription Drug Affordability Resources:

ACS CAN comments to Secretary Alex Azar on Drug Rebate Proposed Rule

Many cancer patients have difficulty affording the cost of their prescription drugs, regardless of whether they are insured.  This is especially true for newer drugs that do not have a generic equivalent.  Many programs exist to help patients afford their medication.  This fact sheet focuses on two of these – patient assistance programs and discount coupons.  

Biological drugs, commonly referred to as biologics, are a class of drugs that are produced using a living system, such as a microorganism, plant cell, or animal cell. Like all drugs, biologics are regulated by the United States Food and Drug Administration (FDA).

Pharmacy benefit managers (PBMs) are entities that administer prescription drug programs for many private, public, and employer health insurance plans. PBMs establish pharmacy networks, negotiate prices with pharmaceutical manufacturers on behalf of their clients, and provide basic claims administration.

For an individual with specific health care needs – like cancer patients and survivors – the drugs covered by a health plan and corresponding cost sharing for each drug is important information when choosing health insurance. However, to make an informed choice, formulary information must be disclosed to the individual.

Prescription drugs are often less expensive in other countries. This is due to a variety of factors. There have been efforts at the state and federal level to allow individuals to purchase lower cost prescription drugs from other countries and import these products into the United States for personal use.

New breakthroughs in cancer research are making more life-saving drug therapies available. Keeping these therapies affordable for patients is imperative. Prohibitive cost sharing for prescription drugs can cause patients to skip dosages, split pills or stop taking their medications entirely, which reduces the effectiveness of their treatment.

Currently, Medicare part D is administered entirely by private plans that follow guidelines set by CMS. Policymakers propose allowing the Secretary of Health and Human Services to enter negotiations between pharmaceutical manufacturers and Part D plans in an attempt to lower prescription drug prices.

Most health insurance plans that cover prescription drugs use formularies to categorize the drugs the plan will cover and determine the amount of patient cost sharing. Divided into “tiers”, the higher the tier, the higher the share of cost for patients.

Private Health Insurance Resources:

ACS CAN comments to Steven Mnuchin and Seema Verma on Iowa's 1332 Waiver

ACS CAN Comments on Massachusetts 1332 Waiver

ACS CAN Comments on Oregon 1332 Waiver

ACS CAN Comments on Iowa 1332 Waiver

ACS CAN submitted comments on the ACA market stabilization rule.

ACS CAN Comments on Special Enrollment Period Verification Pilot Program

ACS CAN Comments on Short-Term Policies

ACS CAN Recommendations for Updating the NAIC's Managed Care Plan Network Adequacy Model Act.

ACS CAN Comments on Proposed Changes to Special Enrollment Periods

Medicare Resources:

ACS CAN comments on CY2018 Medicare Physician Fee Schedule proposed rule

The Medicare program covers 55.3 million people, including 46.3 million who qualify due to age and 9 million people who qualify on the basis of a disability.  Medicare beneficiaries - including many cancer patients and survivors - have access to an outpatient prescription drug benefit that provides them with prescription drugs needed to treat their disease or condition.  This benefit – and keeping it affordable – are crucial to any health care system that works for cancer patients and survivors.

In response to CMS’ calendar year 2017 Medicare Physician Fee Schedule proposed rule, ACS CAN filed comments supporting the proposal to expand the Diabetes Prevention Program (DPP) Model as a new Medicare preventive service because many of the interventions included in the DPP will also help beneficiaries lower their risk of developing cancer.

In response to CMS’ calendar year 2017 Medicare Hospital Outpatient Prospective Payment System proposed rule, ACS CAN filed comments suggesting changes to the Medicare and Medicaid Electronic Health Record Initiative programs and urged Medicare to develop better survey questions that seek to measure a beneficiary’s experience with pain management. 

ACS CAN, the American Heart Association, the American Diabetes Association released a joint statement providing principles for any entitlement reform proposal.

ACS CAN filed comments on the implementation of the Medicare and CHIP Reauthorization Act.

ACS CAN filed extensive comments expressing deep concern with the proposed Medicare Part B Drug Payment Model and noting that in its proposed form the Part B Drug Model Model failed to protect cancer patients' access to life-saving medications.

ACS CAN filed comments on the Advance Notice of Methodological Changes for calendar year 2017 for Medicare Advantage  capitation rates, Part C and D payment policies and the 2017 Call Letter.

ACS CAN provided comments on the proposed rule implementing changes to the Medicare Shared Savings Program in which we urged CMS to provide additional beneficiary education and require greater specificity on wasy to improve care coordination for beneficiaries.

Health Equity Resources:

Despite the fact that US cancer death rates have decreased by 26 percent from 1991 to 2015, not all Americans have benefited equally from the advances in prevention, early detection, and treatments that have helped achieve these lower rates.

On November 10, 2015, ACS CAN hosted the first National Summit on Health Equity in St. Louis, Missouri. The summit brought together over 150 innovative thinkers in public policy, business, technology, academia, patient care, community health, and patient advocacy to examine public policy solutions for assuring greater health equity for cancer patients in the evolving health care system.

Costs and Barriers to Care Resources:

"Surprise billing” is when an insured patient is unknowingly treated by an out-of-network provider and is then billed the difference between what the provider charged, and what the insurer paid. Surprise bills can be significantly higher than the consumer’s standard in-network cost-sharing. 

Many patients with complex diseases like cancer find it difficult to afford their treatments – even when they have health insurance.  Current law establishes a limit on what most private insurance plans can require enrollees to pay in out-of-pocket costs.  These limits protect patients from extremely high costs and are essential to any health care system that works for cancer patients and survivors.

 

The Affordable Care Act (ACA) helps individuals with limited incomes afford their health care coverage by
providing cost-sharing subsidies (like deductibles, coinsurance, and copayments) for silver-level plans
purchased on the health insurance marketplaces. Currently, Congress and the administration are
debating whether to continue funding these cost-sharing reduction subsidies (CSRs). If CSR subsidy
funding is discontinued, health care costs could increase for all marketplace enrollees – regardless of
whether the enrollee qualifies for the CSRs.

This report explores the experiences of cancer patients with their health insurance and financial challenges through interviews with hospital-based financial navigators. The report finds that while the Affordable Care Act has brought crucial improvements to patient access to health insurance, cancer patients still face serious challenges affording their care and using their insurance benefits.

As Congress debates enacting changes to the health care market, one concept re-emerging is state high-risk pools to provide health insurance coverage for individuals who otherwise cannot obtain or afford coverage. High risk pools are not a new concept. Prior to the enactment of the Affordable Care Act (ACA) many states operated some form of high risk pool. During implementation of the ACA, a federal high risk pool was established as an interim step to the new marketplaces. The overall success of high risk pools varied. This fact sheet examines how state risk pools work and the impact on persons with cancer and cancer survivors.

Current federal requirements prohibit health insurance plans from denying coverage to individuals with pre-existing conditions like cancer.  These are one of several important patient protections that must be part of any health care system that works for cancer patients.

Current federal law has several provisions that help prevent individuals and families from experiencing gaps in their health insurance coverage.  Coverage gaps can delay necessary care, which is particularly detrimental to cancer patients and survivors.  Preventing gaps in coverage is a crucial patient protection that must be maintained in our health care and insurance system.

Current federal law provides life-saving coverage of cancer prevention and early detection services and programs.  These provisions are crucial to reducing the incidence and impact of cancer in the United States.  They are also crucial in helping cancer survivors remain cancer-free and lead healthy lives.

The Medicare program covers 55.3 million people, including 46.3 million who qualify due to age and 9 million people who qualify on the basis of a disability.  Medicare beneficiaries - including many cancer patients and survivors - have access to an outpatient prescription drug benefit that provides them with prescription drugs needed to treat their disease or condition.  This benefit – and keeping it affordable – are crucial to any health care system that works for cancer patients and survivors.

Medicaid Resources:

ACS CAN comments on Georgia's 1115 Demonstration Waiver.

ACS CAN comments on Nebraska's 1115 Demonstration Waiver.

An increasing number of states are seeking greater flexibility in administering their Medicaid programs. The Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) give states the opportunity to test innovative or alternative approaches to providing health care coverage to their Medicaid populations through Section 1115 Research and Demonstration Waivers (otherwise known as "1115 waivers"). States must demonstrate that their waivers promote the objectives of the Medicaid and Children’s Health Insurance Programs (CHIP) and CMS must use general criteria to determine whether the objectives of the Medicaid/CHIP programs are met.

 

Medicaid is the primary health insurance program for low-income Americans, offering quality, affordable, and comprehensive health care coverage to millions of people including those with cancer, those who will be diagnosed with cancer, and cancer survivors. Having health insurance through Medicaid helps Americans stay healthy, go to work, care for their families and pay their bills. The Medicaid program also helps communities, hospitals, schools, and economy thrive.

ACS CAN comments on Tennessee's 1115 Demonstration Waiver.

ACS CAN comments on Utah's 1115 Demonstration Waiver.

ACS CAN Comments on Idaho's 1115 Demonstration Waiver.

ACS CAN Comments on Montana's 1115 Demonstration Waiver.

ACS CAN Comments on Utah's 1115 Demonstration Waiver