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Reform Update: Exchange plan drug costs raise discrimination concerns


By Paul Demko
Posted: July 3, 2014 - 3:15 pm ET
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At the end of May, a discrimination complaint was filed with HHS' Office of Civil Rights charging that four insurance companies selling plans in Florida are illegally discriminating against individuals infected with HIV. The complaint accused the health plans—CoventryOne, Cigna, Humana and Preferred Medical–of making drugs inaccessible by attaching expensive co-pays or co-insurance costs.

The plaintiffs, the AIDS Institute and the National Health Law Program, are asking HHS to take steps to remedy the purported discriminatory conduct and financial damages. HHS has acknowledged receiving the complaint, but has not indicated when it might rule on its merits. The insurance companies, meanwhile, maintain that their policies are consistent with HHS guidance.

According to health officials who work closely with people infected with HIV in states across the country, cost concerns aren't limited to Florida. In at least a half dozen other states, including California, Georgia, North Carolina and Texas, there are similar concerns about the cost of HIV drugs on plans sold through the exchanges. Other specialty drugs, such as those for individuals with cancer or multiple sclerosis, are also generating complaints about cost.

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“In the AIDS community we're thinking, what is our next step?” said Carl Schmid, deputy executive director of The AIDS Institute. “Should we file some other complaints?”

Wayne Turner, an attorney with the National Health Law Program, said he worries that other carriers will mimic the behavior of insurance companies charging high costs for specialty drugs in order to avoid attracting customers with expensive, chronic illnesses. “The real danger for these benefit designs isn't even felt in Year One,” Turner said of the exchange policies. “Our concern is that there's going to be a race to the bottom.”

An analysis by Avalere Health (PDF) found that more than 20% of silver plans sold on the exchanges, which are designed to cover 70% of medical costs, required co-insurance payments of 40% for all classes of drugs that target seven types of diseases, including HIV. That study was commissioned by Pharmaceutical Research and Manufacturers of America, a leading industry group, which has been engaged in a war of words with America's Health Insurance Plans over the cost of drugs, particularly the hepatitis C treatment Sovaldi.

The ramifications for individuals with HIV are playing out in different ways across the country. In North Carolina, it appears that many individuals simply decided not to sign up for insurance coverage during the open-enrollment period, according to Allison Rice, supervising attorney at Duke University School of Law's AIDS Legal Project. That decision allows them to remain in the federal AIDS Drug Assistance Program and maintain access to life-saving drugs. But it also means that they have no coverage for other medical concerns as envisioned under the Patient Protection and Affordable Care Act.

“If you're in a car wreck, or you have to have your liver taken out, that is not covered,” Rice said. “The idea was for people to have normal access.”

In Illinois, the AIDS Foundation of Chicago conducted an analysis (PDF) of all drug formularies on plans offered through the exchange in March. It found that plans offered by four out of six insurers operating in the state had cost policies that made drugs unaffordable for “nearly all” individuals living with HIV.

In May, Andrew Boron, director of insurance at the Illinois Department of Insurance, issued a bulletin (PDF) to all health plans doing business in the state, warning them about discrimination against individuals infected with HIV or other diseases. “Any plans found to be discriminatory, whether in design or implementation, will not be recommended for certification or recertification as a Qualified Health Plan that may be sold on the Illinois Health Insurance Marketplace,” Boron wrote.

John Peller, interim president and CEO of the AIDS Foundation of Chicago, said individuals with HIV in the state face an additional problem: Some health plans are refusing to coordinate with the AIDS Drug Assistance Program in order to help provide coverage for expensive drugs.

“By not being able to coordinate with ADAP, the plans are basically saying people with HIV are not welcome here,” Peller said. “It's a barrier to people with HIV enrolling.”

Georgia is experiencing similar problems with expensive HIV drugs on many plans purchased through the exchange, according to Dr. Melanie Thompson, principal investigator for the AIDS Research Consortium of Atlanta. Thompson said health officials there are in the process of putting together a detailed analysis of drug formularies so that people understand the costs when they choose an insurance plan.

They are also trying to determine if Georgia residents who enrolled in plans with drug costs they cannot afford can switch plans outside of the designated enrollment period, which closed at the end of March. The ACA does allow for “special enrollment periods,” but those are typically reserved for individuals who have undergone a life-changing event, such as losing their job or giving birth.

Meanwhile, Thompson said, the state is considering filing a discrimination complaint with HHS similar to the action taken by Florida officials. She's particularly concerned about bringing attention to the issue before the start of the 2015 open-enrollment period on Nov. 15.

“Insurance companies have always tried to figure out ways to not accept or get rid of people with chronic illnesses, especially expensive chronic illnesses, and that goes beyond HIV,” Thompson said. “We want to make it clear that filing plans that are discriminatory is not a strategy that will be successful as we go forward.”

In response to inquiries from Modern Healthcare, the four insurers targeted by the Florida complaint stressed that their exchange plans are fully compliant with the federal healthcare law, and that their coverage policies adhere to the latest guidance from HHS. The insurers also pointed out that they offer a broad array of products that consumers can evaluate to find one that meets their coverage needs.

Preferred Medical further stressed, however, that it takes all complaints seriously. “The complaint filed with the U.S. Department of Health and Human Services regarding HIV medication coverage included in health care plans we offer through the federally facilitated marketplace is no exception,” the Coral Gables, Fla.-based company said in a statement. “To date, we have not received any requests for information from the department, but we stand ready to work with them to address this complaint as necessary.”

Employees like wellness programs, but not their penalties

Though the majority of workers appreciate employer-sponsored wellness programs that encourage healthy behaviors, they don't think it's appropriate for health insurance premiums to be tied to their participation or success at meeting certain health goals. That's according to poll results released this week by the Kaiser Family Foundation, which surveyed more than 1,200 adults on their opinions of corporate wellness programs. About half of respondents who had employer-based insurance said their employer offered some kind of wellness program, but 62% said it wasn't fair for them to pay more if they didn't participate. And three-fourths of those respondents said that if an employee can't meet a health goal, he or she shouldn't have to hand over more money.

Under rules established by the Patient Protection and Affordable Care Act, workers who don't meet what are considered reasonable health goals, such as walking for 30 minutes three times a week, or not smoking, can be charged up to 30% more by employers whose wellness programs meet certain regulatory requirements. –Rachel Landen

Early 2015 insurance exchange rate filings run the gamut

The preliminary picture of 2015 state rate filings for the individual insurance market remains incomplete, but an outline is beginning to materialize, according to data compiled and analyzed by PwC's Health Research Institute. So far, analysts have found wide variations among rate changes across the 17 markets they've studied. Publicly released data shows that premium changes range from a drop of -23% in Arizona to a high of 35% in both Colorado and Indiana. The average rate increase among states already reporting data comes in at 7.22%. —Rachel Landen

Follow Paul Demko on Twitter: @MHpdemko

Follow Rachel Landen on Twitter: @MHrlanden


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