Some insurance companies may be using high-dollar pharmacy co-pays to get around the Affordable Care Act's mandate against discrimination on the basis of pre-existing health problems, Harvard researchers say in the New England Journal of Medicine.
These insurers may have structured their drug coverage to discourage people with HIV from enrolling in their plans through the health insurance marketplaces by putting all HIV medicines, including generics, in the highest cost-sharing category of their drug coverage, the researchers say.
But, says Clare Krusing, director of communications for America's Health Insurance Plans, the findings by definition show that three out of four plans are offering HIV coverage at more reasonable rates. And patients with HIV can choose to move to one of those plans.
"This report really misses that point, and I think that's the overarching component that is important to highlight," Krusing says. "Consumers do have that choice, and that choice is an important part of the marketplace."
Another recent study analyzed drug coverage for several other high-cost chronic conditions — mental illness, cancer, diabetes and rheumatoid arthritis — and found that at least half of the marketplace plans had engaged in discriminatory cost-sharing for one or more of those illnesses, the Harvard researchers say.
The federal government already appears to be taking action, says Lydia Mitts, a senior policy analyst for Families USA, a health consumer advocacy group.
In November, the Department of Health and Human Services released a proposed rule clarifying its stance on discriminatory drug coverage.
"If an issuer places most or all drugs that treat a specific condition on the highest cost tiers, we believe that such plan designs effectively discriminate against, or discourage enrollment by, individuals who have those chronic conditions," the proposed rule says.
Mitts is urging people to call regulators if they believe they're in a plan with discriminatory cost-sharing.
"It's important for consumers to know that if they find themselves in plans like this, they should be reporting it to their state insurance commissioner, the HHS Office of Civil Rights, and their health insurance marketplace," she says.