New Blue Cross Blue Shield of Delaware individual policyholders should cross their fingers and hope they don't need a heart transplant before fall.
Delaware's largest health insurer stopped covering organ transplants for new individual customers last October, blaming the new federal health reform law.
After months of analysis, Blue Cross has decided to reinstate that coverage this October. But as of today, 2 percent of Blue Cross' 400,000 customers -- about 8,000 people -- have plans that don't include transplant coverage, the insurer said.
The transplant rule, which does not apply to insurance that workers receive through their employers, has unnerved area insurance brokers. Some, who requested anonymity to protect their Blue Cross business, said they've asked new Blue Cross customers to sign waivers to protect the brokers from liability.
Health care and insurance experts, meanwhile, called the transplant coverage exclusion highly unusual and potentially shortsighted.
Bills for extended kidney dialysis treatment of kidney failure, for example, can exceed the cost of a transplant, said Dr. Robert Gaston, medical director of the kidney transplant program at the University of Alabama at Birmingham Hospital.
"Each organ has its own benefits, risks and costs and profile," Gaston said. "I would assume that any payer would be aware of these nuances."
According to brokers, insurance companies and state regulators, all of the other major insurers in Delaware's individual market, including Aetna, Coventry and UnitedHealthCare, cover transplants. There are no transplant-specific rider plans.
One major area broker, who asked to remain anonymous to protect his relationship with Blue Cross at a time the company has slashed commission rates, said he's pushing other insurers' policies harder than Blue Cross policies because of the transplant rule.
"They're looking to cut costs any way they can," the New Castle County broker said. "I'm very worried about it. I don't want it to come back and bite me. You're talking about hundreds of thousands of dollars. How is somebody going to pay for that? That's why they need insurance."
State insurance law mandates that all health policies include coverage for certain conditions -- including mental illnesses and supplies for the treatment of diabetes. But organ transplants are not included.
"Does it concern us? Yeah, it concerns us," said Gene Reed, deputy insurance commissioner in Delaware. "But it's a company decision. We can't force them to put things in their policy that are not mandated by state law."
Like state law, federal law does not force insurers to cover transplants.
Robert Laszewski, president of the Washington-area insurance consulting firm Health Policy and Strategy Associates, said Blue Cross is likely trying to lower the cost of its individual insurance policies by excluding organ-transplant coverage.
Laszewski said that many patients who may need a transplant could be weeded out by an insurer through the underwriting process. Insurance companies can deny coverage to adults with pricey pre-existing medical conditions until 2014.
"I'm not so sure what they see as the risk," Laszewski said, noting that the rule is "not at all common."
Transplants are, of course, expensive procedures.
Heart transplants cost $787,700, according to a 2008 report from the consulting and actuarial firm Milliman, which took into account pre-operative expenses as well as medicines needed after a transplant surgery. Kidney transplants run $259,000 and a new lung costs $450,400.
In an emailed statement, Blue Cross said new federal health reform rules that phase out coverage limits triggered the decision to enact the transplant rule. The insurer said that it previously placed a $100,000 limit on transplants. Transplant coverage starting this October will not carry a dollar limit, Blue Cross said.
Health reforms passed last year do empower federal regulators to develop a more detailed list of minimum benefits that insurance policies must cover, said Larry Levitt, a senior vice president at the Menlo Park, Calif.-based Kaiser Family Foundation, a health policy firm.
The list is expected this year. Levitt noted the federal government could mandate a laundry list of benefits, or leave it up to insurers and state regulators to debate the specifics.
"No one knows exactly what the federal government is going to do," Levitt said.