[1]pic thx to trygve ulst on flickr creative commons
For the past two years, patient advocates have complained that many insurers are trying to discourage HIV patients from enrolling in policies sold on health insurance exchanges created by the Affordable Care Act. Now, a new analysis provides fresh evidence that their concerns are justified.
Just 16 percent of the so-called silver exchange plans in 2015 cover all 10 of the most widely used HIV drug regimens. These also cost patients less than $100 per month per regimen, according to Avalere Health, a consulting firm that ran the analysis. There are four types of exchange plans ranked from the most expensive out-of-pocket costs to the least expensive – Bronze, Silver, Gold and Platinum.
But almost half of the silver plans,or 46 percent, include all 10 of commonly used regimens on their formularies, which are lists of drugs that receive preferred insurance coverage. This means a drug typically costs patients less. But many silver plans charge higher out-of-pocket costs for the HIV drugs, according to the analysis [2].
The findings are noteworthy because the vast majority of people who are in health insurance exchanges – 68 percent – are enrolled in silver plans. That works out to about 6.7 million people, according to Caroline Pearson, a senior vice president at Avalere.
Moreover, HIV drugs accounted for 9 percent of drug spending on exchange health plans last year, according to a report [3] by Prime Therapeutics, a pharmacy benefits manager. More was spent on medicines to combat diabetes and hepatitis.
“There are persistent barriers to accessing HIV drugs in exchange markets,” Pearson said. “There’s definitely concern among [the health] plans that HIV patients can be expensive to cover and they don’t want to structure benefits to attract a disproportionate share of enrollees with HIV.”
We should note that the analysis was funded by Gilead Sciences, which makes most of the medicines used in the HIV regimens.
Pearson added that coverage and cost sharing requirements on the silver plans differ from insurance provided by employers. Employer-sponsored insurance typically does not place HIV drugs on so-called specialty tiers that force consumers to pay higher rates – generally, 40 percent to 50 percent of the cost.
We asked America’s Health Insurance Plans, the trade group, for comment and will update you accordingly. [UPDATE: An AHIP spokeswoman sent us this: “The report completely ignores any of the prices or cost associated with these treatments and the fact that health plans are covering the vast majority of the cost.” She also argued the plans are “comprehensive” by covering the widely used regimens, and that the analysis only reflects 2015 plans.]
Nonetheless, the findings did not surprise Carl Schmid, deputy executive director of The AIDS Institute, a patient advocacy group that has been urging federal officials to investigate concerns about discrimination against HIV patients in exchange plans.
“This is further proof that the problem exists around the country,” he said. “And it gives us further ammunition to push for change. We need non-discrimination regulations spelled out clearly.” The AIDS Institute led a coalition of 197 groups that this week urged [4] Health and Human Services Secretary Sylvia Burwell to address discriminatory insurance benefit designs in a rule that implements the Affordable Care Act,
Last year, his group and one other, the National Health Law Program, filed a lawsuit charging four insurers with unlawfully discriminating against people with HIV and AIDS in their Florida health plans. The groups accused the insurers of placing all HIV medications, including generics, on specialty tiers.
Since then, Aetna agreed to lower costs nationwide, while Cigna, Humana and Preferred Medical agreed to do so in Florida. And the Florida Office of Insurance Regulation warned insurers [5] not to overcharge patients for drugs next year.
Meanwhile, the Centers for Medicare & Medicaid Services, which oversees Obamacare, earlier this year responded to the concerns by saying it will scrutinize [6] potentially discriminatory practices for drug benefits in exchange plans for 2016. Plans that place expensive drugs in tiers with high coinsurance or co-pays may be asked to justify their policies.