May 29, 2014

Complainants say health insurers used high drug co-pays to discourage people with HIV/AIDS from enrolling

A complaint being filed with the federal government says some Florida health insurance companies are discriminating against people with HIV/AIDS.

Four Florida insurance companies offering Affordable Care Act policies are discriminating against people with HIV or AIDS, according to two health-rights organizations that plan to file a formal complaint with the federal government Thursday.

The complaint by the AIDS Institute and the National Health Law Program — nonprofits advocating for the health rights of the poor and those living with chronic diseases — cites CoventryOne, Cigna, Humana and Preferred Medical for creating prescription-drug policies that the groups say discourage people with HIV/AIDS from enrolling in their Florida healthcare marketplace plans.

The two organizations, which said they would file the complaint with the U.S. Department of Health and Human Services, claim the insurance companies have placed the HIV/AIDS drugs on their most expensive tiers.

“Not only did the companies place HIV/AIDS drugs in the plans’ highest formulary tiers — even generic drugs — they required prior authorization for any HIV/AIDS medication,” said Wayne Turner, the National Health Law Program staff attorney who drafted the complaint. Turner said he could find no justification for such a benefit design. “From our reading, the companies were looking for a way around the ACA’s protections to discourage people with HIV/AIDS from enrolling in their plans.”

Before the ACA, health insurance companies routinely denied coverage to people with preexisting conditions, including HIV/AIDS. While the federally funded Ryan White program helps the poorest afford care for the illness, those with incomes above 400 percent of the federal poverty level had to bear the entire cost of treatment, which can sometimes top $1,000 a month for medications alone. The Florida HIV/AIDS and Hepatitis Program estimates that at least 130,000 people live with HIV/AIDS in the state.

The Affordable Care Act ended denial of coverage for preexisting conditions and, with the opening of the healthcare marketplace in October 2013, people with HIV/AIDS could enroll in health insurance for the first time under the ACA.

But an analysis by the AIDS Institute of Florida’s silver-level health plans found that the four companies placed HIV and hepatitis drugs in their highest formulary tiers, meaning that people who need those drugs must pay the highest out-of-pocket costs for them. According to the study:

• CoventryOne places all HIV drugs in Tier 5 of its formulary, requiring a 40 percent co-insurance after a $1,000 prescription deductible.
• Cigna also places all HIV and hepatitis drugs in Tier 5 with 40 percent co-insurance after a deductible ranging from $0 to $2,750.
• Humana places all HIV and hepatitis drugs in Tier 5 with a 50 percent co-insurance after a $1,500 deductible.
• Preferred Medical places all HIV drugs and all but two hepatitis drug in a Specialty Tier requiring 40 percent co-insurance.

In each case, most or all of the drugs require prior authorization.

The companies’ plans appear to be outliers in Florida’s healthcare marketplace, since other participating insurers have taken a different approach to their formularies. Florida Blue, for example — which has the largest share of silver plans on Florida’s healthcare exchange — places most HIV drugs on either Tier 1 or Tier 2, requiring a co-payment of between $10 and $25 for Tier 1 drugs, and a co-payment of between $40 and $70 for Tier 2 drugs. A deductible must be met first in some cases.

Cigna spokeswoman Karen Eldred responded, “Cigna plans provide access to HIV care and prescription drugs that not only follow the latest HHS guidelines and evidence-based practices, but also provide comprehensive customer support through a dedicated condition-specific team consisting of nurses, pharmacists and therapy support coordinators. The plans include coverage for all medically necessary HIV drugs.”

Eldred added that Cigna offers a variety of benefit options so “consumers can pick one that best meets their needs. There are plans that offer the flexibility of a higher deductible and lower monthly premium and those that have higher premiums and lower cost sharing for greater predictability.”

Efforts to reach the other insurers were unsuccessful.

Neither the Florida Office of Insurance Regulation or the Agency for Healthcare Administration reviewed the benefit designs of the 2014 qualified health plans for the state’s health insurance marketplace.

“The practice of these four companies is not the market norm. Nor is it a necessity,” Turner said. “The big advance of the ACA is that health-plan benefit designs cannot prevent people from fully enjoying the benefits available to them. That’s what we’re alleging in this complaint.”

This story was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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