Highlight on Washington: State Imposes 90 Day Waiting Period on Transplants for the Newly Insured

Newly insured health care consumers in Washington State who purchased their health plans from Premera Blue Cross, BridgeSpan Health, Moda Health and Group Health through the state’s online exchange  are required to wait up to 90 days from when their insurance begins before coverage for transplants will be covered, according to a recent Washington Post article.

The waiting period imposed is based on whether the member had coverage before under a different plan. If a member was enrolled in a different plan for 90 days prior to incurring transplant related expenses then they would be exempt. If they had coverage for less than 90 days the exclusion period will be reduced day for day for each day they were covered by the prior coverage. For example, if member was enrolled in another insurance plan for 45 days, the exclusionary period would be reduced by 45 days.

The waiting period is a holdover from the days when insurers were able to impose restrictions on coverage for all sorts of preexisting conditions. Medical professionals who treat patients with chronic and terminal illnesses that may require transplants are not happy. They say there is no requirement or medical basis for the waiting period. The question at issue is whether these providers who are imposing waiting times for transplants violating the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) by discriminating against patients with these specific diseases that require transplants. Insurers say no. They claim that they are complying with what is allowed under the Washington state law. Stephanie Marquis, a spokeswoman for the Washington state insurance commissioner’s office, said the wait time for transplants for plans has been lowered “to match what was allowed under federal law.” Insurers also claim that the wait time applies to the entire process and since that process can take years they are not discriminating.

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

In Oregon, patient advocates successfully fought against a similar provision that allowed insurers to impose a 24-month waiting period for transplants. In that state, the insurance commissioner eliminated that rule on Dec. 31 and told insurers there should be no waiting period.

The ACA prohibits “excessive waiting periods.” Excessive is defined as more than 90 days. What the ACA does not indicate is whether specific benefits can be subject to waiting periods and different states are interpreting the law in different ways.