Patient groups protest Washington state insurance rules

By Ariana Eunjung Cha

The Washington Post

Newly insured consumers in Washington state who purchased health plans through the online exchange might find a surprise when they comb through the fine print in their policies: They’ll have to wait 90 days from when their insurance begins before coverage for transplants will kick in.

The waiting period, a holdover from the days when insurers were able to impose restrictions on coverage for all sorts of preexisting conditions, has become the latest flash point in the often tense negotiations between insurers, regulators, doctors and consumers over the design of the new individual and small-group health plans that went into effect Jan 1.

Specialists who treat patients with cancer, heart disease and other chronic illnesses are outraged by the requirement and say there is no medical basis for it. They accuse insurers of violating Affordable Care Act provisions that prohibit discrimination against those with specific diseases.

The waiting-period rule, which is in effect for policies sold by Premera Blue Cross, BridgeSpan Health, Moda Health and Group Health, applies to the entire transplant process, meaning that patients must wait 90 days before even beginning an evaluation. The evaluations, which include everything from screening tests to interviews with social workers and nutritionists, often take several months. Once a patient is approved, the wait on a transplant list could be several more months or even years, depending on the person’s condition, the organ involved, and the hospital.

“The whole idea of creating a waiting period for someone who is dying of organ failure is the antithesis of what the Affordable Care Act is supposed to be about,” said Roslyn Mannon, immediate past president of the American Society of Transplantation and a transplant nephrologist at the University of Alabama at Birmingham.

Susanna Nazarian, assistant professor of transplant surgery at the University of Washington, put it more bluntly: “Putting this additional barrier in front of them will lead to some patients passing away.”

Insurance company representatives said they were complying with what is allowed under the Washington state benchmark plan. Stephanie Marquis, a spokeswoman for the Washington state insurance commissioner’s office, said the original waiting period for transplants for plans purchased through the state exchange was six months but it was reduced to 90 days “to match what was allowed under federal law.”

Marquis said the insurance office has since heard from consumers who think that any waiting period is discriminatory, and that the office is looking into the issue further.

“I can’t give you a specific time frame yet, but we do take their concerns seriously,” she said.

The waiting periods apply only to those who did not have prior coverage. If a member had been continuously enrolled in a different plan 90 days prior to incurring the transplant-related expenses, he or she would be exempt. If a member had coverage for less than 90 days, the exclusion period is reduced by one day for each day of prior coverage.

Patient advocates have successfully pushed back against a similar provision in Oregon that allowed insurers to impose a 24-month waiting period for transplants. The insurance commissioner eliminated that rule on Dec. 31 and told insurers there should be no waiting period.

Sandy Praeger, past president of the National Association of Insurance Commissioners and the head of the insurance department in Kansas, said she has not heard about similar restrictions on transplants in other states, but she expects more issues to arise in the coming year as consumers who purchased the plans start to visit doctors. “It’s something that might not surface until people start exercising their benefits. They may not realize the waiting period was in there,” she said.

The Affordable Care Act prohibits “excessive” waiting periods, which it defines as more than 90 days. But it does not indicate whether specific benefits could be subject to a waiting period, and state officials have interpreted the law in different ways.

Talk to us

> Give us your news tips.

> Send us a letter to the editor.

> More Herald contact information.

More in Business

Black Press Media operates Sound Publishing, the largest community news organization in Washington State with dailies and community news outlets in Alaska.
Black Press Media concludes transition of ownership

Black Press Media, which operates Sound Publishing, completed its sale Monday (March 25), following the formerly announced corporate restructuring.

Maygen Hetherington, executive director of the Historic Downtown Snohomish Association, laughs during an interview in her office on Thursday, Feb. 15, 2024, in Snohomish, Washington. (Ryan Berry / The Herald)
Maygen Hetherington: tireless advocate for the city of Snohomish

Historic Downtown Snohomish Association receives the Opportunity Lives Here award from Economic Alliance.

FILE - Washington Secretary of State Steve Hobbs poses in front of photos of the 15 people who previously held the office on Nov. 22, 2021, after he was sworn in at the Capitol in Olympia, Wash. Hobbs faces several challengers as he runs for election to the office he was appointed to last fall. (AP Photo/Ted S. Warren, File)
Secretary of State Steve Hobbs: ‘I wanted to serve my country’

Hobbs, a former Lake Stevens senator, is the recipient of the Henry M. Jackson Award from Economic Alliance Snohomish County.

Mark Duffy poses for a photo in his office at the Mountain Pacific Bank headquarters on Wednesday, Feb. 14, 2024 in Everett, Washington. (Annie Barker / The Herald)
Mark Duffy: Building a hometown bank; giving kids an opportunity

Mountain Pacific Bank’s founder is the recipient of the Fluke Award from Economic Alliance Snohomish County.

Barb Tolbert poses for a photo at Silver Scoop Ice Cream on Thursday, Feb. 29, 2024 in Arlington, Washington. (Annie Barker / The Herald)
Barb Tolbert: Former mayor piloted Arlington out of economic brink

Tolbert won the Elson S. Floyd Award, honoring a leader who has “created lasting opportunities” for the underserved.

Photo provided by 
Economic Alliance
Economic Alliance presented one of the Washington Rising Stem Awards to Katie Larios, a senior at Mountlake Terrace High School.
Mountlake Terrace High School senior wins state STEM award

Katie Larios was honored at an Economic Alliance gathering: “A champion for other young women of color in STEM.”

The Westwood Rainier is one of the seven ships in the Westwood line. The ships serve ports in the Pacific Northwest and Northeast Asia. (Photo provided by Swire Shipping)
Westwood Shipping Lines, an Everett mainstay, has new name

The four green-hulled Westwood vessels will keep their names, but the ships will display the Swire Shipping flag.

A Keyport ship docked at Lake Union in Seattle in June 2018. The ship spends most of the year in Alaska harvesting Golden King crab in the Bering Sea. During the summer it ties up for maintenance and repairs at Lake Union. (Keyport LLC)
In crabbers’ turbulent moment, Edmonds seafood processor ‘saved our season’

When a processing plant in Alaska closed, Edmonds-based business Keyport stepped up to solve a “no-win situation.”

Angela Harris, Executive Director of the Port of Edmonds, stands at the port’s marina on Wednesday, Jan. 24, 2024, in Edmonds, Washington. (Ryan Berry / The Herald)
Leadership, love for the Port of Edmonds got exec the job

Shoring up an aging seawall is the first order of business for Angela Harris, the first woman to lead the Edmonds port.

The Cascade Warbirds fly over Naval Station Everett. (Sue Misao / The Herald file)
Bothell High School senior awarded $2,500 to keep on flying

Cascade Warbirds scholarship helps students 16-21 continue flight training and earn a private pilot’s certificate.

Rachel Gardner, the owner of Musicology Co., a new music boutique record store on Thursday, Jan. 18, 2024 in Edmonds, Washington. Musicology Co. will open in February, selling used and new vinyl, CDs and other music-related merchandise. (Olivia Vanni / The Herald)
New Edmonds record shop intends to be a ‘destination for every musician’

Rachel Gardner opened Musicology Co. this month, filling a record store gap in Edmonds.

MyMyToyStore.com owner Tom Harrison at his brick and mortar storefront on Tuesday, Sept. 6, 2022 in Everett, Washington. (Olivia Vanni / The Herald)
Burst pipe permanently closes downtown Everett toy store

After a pipe flooded the store, MyMyToystore in downtown Everett closed. Owner Tom Harrison is already on to his next venture.

Support local journalism

If you value local news, make a gift now to support the trusted journalism you get in The Daily Herald. Donations processed in this system are not tax deductible.