-- Some Drug Coverage Offered on Affordable Care Act's New Exchanges Requires Steep Payments
A coalition of 31 HIV/AIDS organizations is urging the Obama administration to investigate whether some health insurers are trying to discourage HIV-infected patients from enrolling in new policies being sold under the health-care law, a move the groups say could be illegal.
The Affordable Care Act prohibits discrimination against people who are sick; insurers can't deny them coverage or charge them more than healthier peers.
But in a letter to Secretary of Health and Human Services Kathleen Sebelius last week, the coalition said it had noticed "a number of disturbing trends" in plans on the insurance exchanges, including plans that don't cover all available HIV drugs and what it termed "egregious cost-sharing designs."
What constitutes discrimination under the health law isn't clear, legal experts say, because the administration has yet to issue guidance.
Experts including the Center on Health Insurance Reforms at Georgetown University's Health Policy Institute are studying the issue. "You are not supposed to design policies that discriminate, but what does it mean for a plan to be discriminatory? We don't know that yet," said Kevin Lucia, a research professor at the institute.
Among examples the HIV/AIDS coalition cited:
Aetna Inc. requires patients to pay 50% of the cost, after a drug deductible, for most HIV drugs in Florida. In Florida and some other states, Cigna Corp. and Aetna's separate CoventryOne put all HIV drugs—including generics—in a special category, requiring patients to pay 40% to 50% of their cost. That can be thousands of dollars a month.
Humana Inc. 's posted list of covered drugs in Florida and Alabama lists only six HIV drugs; other drugs are on a separate specialty list that shoppers might not know to check, the group says. All require patients to pay 50% of the cost, after a separate drug deductible.
For most drugs, insurers have traditionally required patients to pay only a flat copay, generally $10 to $50.
A spokeswoman for HHS said Tuesday, "We are looking into the issue of HIV drug coverage to see if further action is needed." She added that "all marketplace plans are required to cover prescription drugs, allowing many consumers to be able to access the medicines they need for the first time."
A spokeswoman for Cigna said it offered a variety of options that allow customers to pick a plan that best meets their needs. A spokesman for Aetna and Coventry said its plans provide access to HIV care that follow the latest HHS guidelines and evidence-based practices.
A spokesman for Humana said people researching plans on the exchanges should use the tools at humama.com for the most accurate information about particular drugs.
The HIV/AIDS groups haven't received a response from their Dec. 2 letter, said Robert Greenwald, director of the Center for Health and Law Policy Innovation at Harvard University and co-chair of the coalition. "This matters a lot to people living with HIV," he said.
Mr. Greenwald said that after discussions with his organization, some insurers had agreed to add coverage of new HIV drugs called single-tablet regimes, which combine several older drugs. "We've made some progress there," he said. But he added, "We cannot view it as a sufficient step forward if the copayment is so high that the drug is all but inaccessible to many patients."
Most HIV/AIDS organizations are very supportive of the new health law. Only about 17% of the estimated 1.1 million HIV-infected Americans are covered by private insurance, according to the AIDS Institute, and many will now qualify for private plans or Medicaid under its expansion. In many states, government programs also help HIV patients with out-of-pocket costs for drugs and premiums.
Even before the Affordable Care Act, insurers increasingly had been requiring patients to pay up to 50% of the costs of so-called specialty drugs, which typically are those that require special handling, need to be injected or infused and can costs thousands of dollars a month.
But some AIDS advocates say that some insurers seem to be singling out all HIV drugs, even generics, with high cost-sharing fees.
"Why is it every HIV drug, no matter how old it is, how costly it is, gets on the highest tier?" asked Carl Schmid, deputy director of the AIDS Institute in Washington.
He also noted that some insurers, including BlueCross BlueShield plans in many states, require relatively low, flat copays for HIV drugs. "Why can BlueCross BlueShield charge reasonable fees—but not Humana or Aetna?" Mr. Schmid said.
Robert Zirkelbach, a spokesman for America's Health Insurance Plans, an industry group, said the health law spreads the risks, requiring plans that attract a disproportionate share of healthy enrollees to help pay for those plans with sicker, costlier patients. Health plans, he said, "are doing everything they can to keep coverage as affordable as possible."
Write to Melinda Beck at HealthJournal@wsj.com