June 9, 2014
The AIDS Institute and the National Health Law Program (NHLP) filed a complaint with the U.S. Department of Health and Human Services (HHS)'s Office for Civil Rights on May 29 charging four insurers (CoventryOne, Cigna, Humana and Preferred Medical Plan) in Florida with violating the antidiscrimination provision of the Affordable Care Act (ACA), reported The New York Times. All four insurers have instituted restrictions on HIV drugs, and/or placed them on the highest payment "tier" of the midlevel "silver" exchange plans, causing patients' medication costs to skyrocket.
The AIDS Institute conducted an analysis of the prescription drug formularies and cost structure for all silver-level Qualified Health Plans (QHPs) operating in Florida. The analysis found that, of the 36 plans reviewed, the QHPs offered by the four companies charge inordinately high co-payments and coinsurance for HIV medications. According to the Times, all four companies claim that their HIV drug coverage is "in line with accepted medical practice and met requirements." However, other Florida insurers offer plans with reasonable co-pays, though a high deductible may also need to be met.
People living with HIV, as well as those with cancer, multiple sclerosis or other conditions that require expensive drugs to be taken regularly, may be forced to learn the unfortunate truth that coverage does not equal care. Practices such as these that result in driving HIV-positive people away from the most affordable plans -- known as "lemon dropping" -- are the insurance industry's answer to the provision of the ACA (or "Obamacare") that prohibits discrimination against people with preexisting conditions. Many people who purchased these plans are now facing higher out-of-pocket costs than they are able to pay -- deductibles starting at $1,000, as well as 40%-50% co-pays.
While this case pertains to the Florida exchange, similar practices have been reported elsewhere, including the 20 states (mostly in the South and the West) that have refused to expand Medicaid. According to Jennifer Kates, the director of global health and HIV policy at the Kaiser Family Foundation, this case will be watched closely, not only by the HIV community, but also by those living with other serious illnesses and their advocates. If the HHS sides with the HIV advocates, it would mean "this couldn't happen for those with diabetes or any other kind of condition."
Advocates have noted that all who shop for exchange policies, HIV positive or not, must take time to understand exactly what they're buying. Too often, shoppers look for the lowest monthly premium, not realizing that they may end up paying for insurance they can't use due to high deductibles, co-pays and coinsurance.
The Florida case reinforces that all who depend on adherence to a medication regimen to control their medical condition must also check the formulary of the plan they're considering to make sure their drugs are covered and to find out exactly how much they can expect to pay.
"We trust the Administration will take immediate action against these four insurance companies and send a strong message that this practice is illegal and discrimination against people with HIV/AIDS will not be tolerated," said Carl Schmid, the deputy executive director of The AIDS Institute, in a press release. "If they do not, other plans in Florida and across the country could adopt these very same discriminatory practices. This would make insurance coverage impossible for people with HIV/AIDS, and jeopardize their health and well-being."
Sue Saltmarsh has worked in the HIV/AIDS field for over 20 years, the first 10 as an herbalist and energy therapist at Project Vida, the last six as a writer and copy editor for Positively Aware magazine. She is now a freelance writer and editor and is also able to devote more time to her passion as founder and director of the Drive for Universal Healthcare (DUH).