Insurance loophole jeopardizes cancer treatment

A pile of papers on Maria Silva's table foreshadows doom.


DALLAS — A pile of papers on Maria Silva's table foreshadows doom.

One says her breast cancer has spread.

Another is a cancellation notice from BlueCross BlueShield because her policy doesn't meet the new federal standards.

A third says her long-time oncologist won't be accepting policies from the new federal health care program.

"It's shocking,” Silva said. “Where am I supposed to go? Where am I supposed to go for treatment?"

Silva and thousands of Texas Oncology patients recently received the letter that says:

"Texas Oncology will not participate as an in-network provider for the HIMP (Health Insurance Market Place) ... We understand that these changes have a significant impact to our patients, both clinically and financially."

Texas Oncology treats tens of thousands of cancer patients at more than 135 sites across the state and in Oklahoma.

Deciding against accepting insurance offered in the health care marketplace,, might be blamed on a complicated loophole in the Affordable Care Act that could cost oncologists and countless other medical providers lots of money.

According the law, patients who haven't paid premiums are given a 90-day grace period before their coverage is dropped. But the insurance company isn't obligated to pay the claims for the last two months of that period.

"The doctors and hospitals could easily treat a patient for one, two, even three months, without fully understanding they are not insured,” explained Devon Herrick with the National Center for Policy Analysis, a non-partisan think tank based in Dallas.

That might provide too much financial risk for health care providers — especially those providing expensive, long-term care, like cancer treatment.

The American Medical Association has written about fears of widespread unpaid claims. According to American Medical News:

"Physicians, hospitals and other health care providers cannot reasonably be expected to know or predict if an enrollee’s premiums are paid or will be paid before the end of the grace period," officials from the Missouri State Medical Association and the Missouri Hospital Association stated in an August 12 letter to the Centers for Medicare and Medicaid Services. "And they cannot reasonably be expected to bear the concomitant burden of uncertainty and a potentially significant financial loss."

Other organizations, including the American Society of Cataract and Refractive Surgery, have informed physicians that they are tracking the problem and have asked federal officials to solve the 90-day grace period loophole.

Texas Oncology declined an on-camera interview, providing this statement to News 8:

“Texas Oncology has made no decision regarding participation in the Health Insurance Marketplace created by the Affordable Care Act. At this early stage, it is not clear how the new insurance plans will cover cancer treatment, together with related care that our patients need.

"Knowing what is covered before, during, and after cancer treatment impacts our ability to determine and deliver the most effective overall courses of treatment to our patients. That’s why a decision about participation at this stage would be premature.

"Like many health care providers, we are carefully reviewing the more than 100 plans in the insurance marketplace, and will determine our approach based on what’s best for our patients and our physicians’ ability to deliver the best cancer care possible to patients in Texas.

"During the transition ahead, Texas Oncology will continue to provide financial counseling to patients — consistent with our long-standing practice — to help them understand their medical and financial options."

"If I decided not to have treatment, I would be dead in two to three months,” Maria Silva said. "I have to have it."

She prays the loophole is closed so she can find the lifesaving care she needs before it's too late.

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