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Patient Access to Oncology Care in ACA Exchange Plans
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Patient Access to Oncology Care in ACA Exchange Plans

Caroline F. Pearson and Deirdre B. Parsons, MPP, MPH, MS
This article describes provider networks and benefit design-including deductibles, cost-sharing, and maximum out-of-pocket limits-for oncology care in 2015 health insurance exchanges.
Beginning in 2016, the ACA will also require HHS to release an enrollee sat­isfaction survey to assess consumer experience with exchange plans.8 The information collected from the surveys will be publicly displayed to allow indi­viduals to compare satisfaction across plans. The survey will include questions on access to specialists and cost sharing for medications.

As we enter 2016, patients with cancer who are enrolling in coverage through the exchanges need to recog­nize the unique characteristics of this market that may impact their access to services and the costs associated with treatment. Careful selection of a health plan can help consumers anticipate and minimize their OOP costs. EBO

Caroline F. Pearson is senior vice president at Avalere Health, an Inovalon Company.
Deirdre B. Parsons, MPP, MPH, MS, is senior manager at Avalere Health, an Inovalon Company.
Corresponding Author

Caroline Pearson
1350 Connecticut NW, Suite 900
Washington, DC 20036

*This work was self-funded by Avalere Health.

1. Health Insurance Marketplaces 2015 open enrollment period: March enrollment report. HHS website. Published March 10, 2015. Accessed November 4, 2015.
2. Brot-Goldberg ZC, Chandra A, Handel BR, Kolstad JT. What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics. National Bureau of Economic Research website. Published October 2015. Accessed November 3, 2015.
3. Center for Consumer Information & Insurance Oversight. Health insurance marketplace public use files (Marketplace PUF). CMS website. Accessed November 3, 2015.
4. Avalere Health analysis of 2015 exchange network designs using its proprietary PlanScape database. Avalere analyzed exchange and commercial plan networks in the largest cities in the 5 states with the largest 2015 exchange enrollment (FL, CA, TX, GA, and NC) using data provided by Strenuus (proprietary information).
5. Avalere Health analysis of 2015 exchange formularies using the PlanScape database. Avalere analyzed formularies for silver plans participating in 8 states (CA, FL, GA, IL, NY, NC, PA, and TX) using data from Managed Markets Insight & Technology, LLC and the 2015 HHS Individual Market Landscape File. Oncology classes included are antiangiogenic agents, antimetabolites, emetogenic therapy adjuncts, and molecular target inhibitors. This analysis is based on data collected by Managed Markets Insight & Technology, LLC (proprietary information).
6. Pearson CF, Choe SH. Leading cancer centers may be more widely included in exchange networks than expected. Avalere Health website. Published April 22, 2015. Accessed October 21, 2015.
7. Final HHS Notice of Benefit & Payment Parameters for 2016. CMS website. Accessed November 3, 2015.
8. Section 1311(c)(4) of the Affordable Care Act. US Government Publishing Office website. Accessed November 3, 2015.
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