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Are Insurers Finding a Way Around Obamacare Preexisting-Conditions Protections?

HIV advocates worry some insurers are steering patients away from their plans by offering limited treatment options and insufficient information.

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(Photo by Mario Tama/Getty Images)

The Affordable Care Act prohibits insurers from denying coverage to individuals with preexisting conditions, but some companies may be limiting their prescription-drug offerings to steer HIV patients to other plans.

"We're seeing policies in place by insurance companies that certainly look like they are intended to make plans look less attractive to patients with HIV," said John Peller, vice president of policy at AIDS Foundation of Chicago.

 

There are two main concerns with the policies in question: that companies are not offering single-tablet regimens (STRs) for HIV patients in their Quality Health Plan formularies (the list of prescription medicines covered), and that there is a lack of transparency as far as what the plans offer to individuals with the disease.

Advocacy groups are observing this across a number of major insurance companies in a large number of states.

The HIV Health Care Access Working Group (HHCAWG), a coalition of national HIV health policy advocates, has sent letters to insurance companies and to Health and Human Services Secretary Kathleen Sebelius regarding the issue.

 

"We're making sure that formularies are robust, and [insurance companies] are not utilizing management techniques—like tiering or prior approval—that create unfair or undue burdens on people to meet their standard of care," says Robert Greenwald, director of the Center of Health Law and Policy Innovation at Harvard Law School, and a cochair of HHCAWG. Greenwald is the main individual behind the effort, and point person on the letters.

STRs are crucial to quality HIV treatment, allowing patients to take only one pill a day. STRs "are the most frequently taken HIV drugs, and have absolutely revolutionized care for people with HIV," Peller says. "There is strong evidence that shows someone with HIV on a single-tablet regimen is more likely to stick to their regimen." Studies show that STRs reduce hospitalizations by 23 percent and overall medical costs by 17 percent.

"The hope is to call attention to this, given that compounds are very effective and not more costly than their component parts," Greenwald says. He says that part of the reason companies are not offering STRs is the way that Centers for Medicare and Medicaid Services guidelines to issuers are currently written—different dosages, concentrations, and delivery methods of a drug are considered the same if they have the same components.

Advocates worry not only that the STRs are not available on some plans, but also that information regarding what is available is extremely difficult to find.

 

"Some companies post a subset of formularies and not the whole one," says Andrea Weddle, executive director of the HIV Medicine Association and another cochair of HHCAWG. "It can be misleading and makes it difficult for people with more chronic conditions to make sure their specific medicine is available." Weddle says information is highly variable from state to state and insurer to insurer, in terms of how much transparency there is in the plans offered.  

"I do think we have some concerns that [plans] lack transparency," Greenwald concurs. "If people don't see their medications, see them only available with cost-sharing that is highly-tiered, or other management techniques to make it difficult to access the care [patients] want—if that is seen happening targeted at any condition—that would be a discriminatory practice."

Advocates say it is too soon to tell whether these policies are intended to steer away HIV patients, and the issue falls into a bit of a gray area as far as antidiscrimination protections in the ACA. HHS regulations allow plans some flexibility, but they are required to cover at least one drug in every class, as well as the number of drugs in the state benchmark plan. 

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"If it appears a plan is designed, or marketing is specifically designed, to discourage enrollment, that would rise to the level [of discrimination]," Greenwald says. "We're monitoring to make sure that doesn't happen."

Greenwald says he has already received some responses to the letter from insurance companies, saying they reevaluated their coverage and are now planning to include STRs in their plans.

BlueCross BlueShield WellPoint responded saying it would offer Atripla—the first HIV regimen in one daily pill—though WellPoint spokeswoman Lori McLaughlin says this change was already in the works.

"WellPoint affiliated plans will all offer Atripla," she wrote in an email. "However, similar to our approach in all drug classes, not all HIV drug combinations will be included on formulary, just as all combinations are not offered in other drug classes. In most states, specialty drugs are offered on Tier 3 or Tier 4, which requires co-insurance."

"It's great," Greenwald says of the responses he's received thus far. "We've identified a problem that could have been very serious, and there's some indication we may be able to resolve it by watching closely and holding companies accountable."

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