Washington Eliminates Waiting Period for Transplant Coverage

By Sandy Ahn, Research Fellow, Georgetown University Center on Health Insurance Reforms

I recently blogged about a May 16th federal guidance that prohibits insurers from imposing benefit-specific waiting periods on their enrollees. I noted also that this was an issue that had arisen in Washington state, where some insurers were imposing a 90-day waiting period for people needing transplants. In response to concerns about those policies and supported by the federal guidance, last week the Washington insurance department finalized a regulation prohibiting insurers from imposing a 90-day waiting period for transplants.

What’s the issue?

In their May 16th guidance, federal regulators concluded that benefit specific waiting periods run afoul of the ACA’s requirement that individual and small group health plans cover ten categories of critical benefits such as hospitalization, prescription drugs, and ambulatory services, referred to as essential health benefits (EHB). Individual and small group health plans must not only cover EHB, but also cannot design their plans in a way that would discriminate based an individual’s medical condition and other factors like age or present or predicted disability. Since a waiting period for a transplant would be discriminatory towards people with conditions that would need a transplant, like kidney or heart disease, federal guidance prohibits them.

Once the federal guidance was issued, Washington initiated emergency procedures to align their insurance rules to the ACA. While Washington’s rule is effective now, Washington is not requiring health plans to amend the actual language in their policies mid-year. Rather, the state is requiring insurers to identify and to notify any consumers that may be affected by this change. Language in 2015 policies, however, must reflect this change.

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