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.

NEW YORK, NY - JUNE 27: A sign for free HIV testing is seen outside a Walgreens pharmacy in Times Square on June 27, 2012 in New York City. June 27 is National HIV Testing Day and the Centers for Disease Control and Prevention is rolling out a new program offering free rapid HIV testing in pharmacies in 24 cities and rural communities.
National Journal
Sophie Novack
Add to Briefcase
Sophie Novack
Nov. 7, 2013, 12:49 p.m.

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. 

“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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