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HIV Groups File Federal Complaint Against Insurance Companies for "Discrimination" - "Overly Restrictive" "Unduly Limits Access", Charging High Copays & Coinsurance
 
 
  Download the PDF here
 
...... "Dr. Jose Lares-Guia, a Manhattan solo practitioner who has a large HIV practice, says some of his patients are maxing out their credit cards or going without medication."......."the way drug pricing is structured, people with HIV and AIDS would have to pay more than $1,000 a month for their treatments.....problem isn't limited to Florida and they are seeing the same kinds of behavior from insurers in states such as Illinois"......from Jules: why was this problem not anticipated, a failure for people with HIV.....The National Health Law Program and The AIDS Institute have filed a complaint against CoventryOne, Cigna, Humana and Preferred Medical in Florida with the Office of Civil Rights at the Department of Health and Human Services alleging that their ObamaCare plans are overcharging for treatments: requesting that federal officials take action to end discrimination targeting people living with HIV/AIDS.The complaint alleges four Florida insurers (CoventryOne, Cigna, Humana and Preferred Medical) are violating the Affordable Care Act (ACA) and federal civil rights laws by structuring their prescription drug policies in a way that discourages people with HIV/AIDS from selecting their plans. The COMPLAINT says: ".....drug benefits offered by CovebtryONE, Cigna, Humana & Preferred Medical impose overly restrictive utilization management which unduly limits access to commonly used HIV/AIDS medications....by placing allHIV/AIDS medications, including generics, on the highest cost-sharing tier [these companies] discourage people living with HIV & AIDS from enrolling in their health plans, a practice which unlawfully discriminates on the basis of disability"

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Another issue is transparency. Schmid said right now, it's difficult to find out if drugs are covered under certain plans. "We had an awful time figuring out which drugs were being offered on the plans as well as what the costs of the drugs were."
 
The groups say they want their complaint to prompt HHS to more closely scrutinize all insurers plans submitted for next year.
 
Insurers have already been submitting their plans for next year, though they won't be finalized until the fall. "We want it to influence the review of the 2015 plans," Schmid said. "We hope there will be greater scrutiny when these plans come in about how insurers designed their plans."
 
"Dr. Jose Lares-Guia, a Manhattan solo practitioner who has a large HIV practice, says some of his patients are maxing out their credit cards or going without medication."
 
"Another issue is transparency. Schmid said right now, it's difficult if drugs are covered under the plans, as well as what the costs of the drugs were"...... http://www.thefiscaltimes.com/Articles/2014/07/10/Obamacare-Insurers-Hit-High-Cost-Patients-High-Drug-Prices Another issue is transparency. Schmid said right now, it's difficult to find out if drugs are covered under certain plans. "We had an awful time figuring out which drugs were being offered on the plans as well as what the costs of the drugs were."
 
The groups say they want their complaint to prompt HHS to more closely scrutinize all insurers plans submitted for next year.
 
Insurers have already been submitting their plans for next year, though they won't be finalized until the fall. "We want it to influence the review of the 2015 plans," Schmid said. "We hope there will be greater scrutiny when these plans come in about how insurers designed their plans."
 
Pharmaceutical Research and Manufacturers of America Study: http://thehill.com/policy/healthcare/208994-drug-makers-launch-counter-attack-on-insurers..........By placing HIV medications on the top formulary tiers, the plans are restricting access to life-saving treatment, directly countering the intent of meaningful health reform and placing patients at significant risk." ......Over 20% or more of Silver plans require coinsurance of 40% or more.....Many Exchange Plans Burden the Most Vulnerable Patients with High Out-of-Pocket Costs for Vital Medicines .......findings reveal that in seven of 19 classes of medicines for serious illnesses, such as cancer, HIV/AIDS, autoimmune diseases such as rheumatoid arthritis and multiple sclerosis, and bipolar disorder, more than 20 percent of Silver plans require coinsurance of 40 percent or more for all drugs in those classes. Similarly, in 10 of the 19 selected classes, at least 20 percent of Silver plans require coinsurance of 30 percent or greater for drugs in the classes.........http://www.phrma.org/media-releases/many-exchange-plans-burden-the-most-vulnerable-patients-with-high-outofpocket-costs-for-vital-medicines
 
Is Obamacare Living Up to Its Preexisting-Conditions Promise?........http://www.nationaljournal.com/health-care/is-obamacare-living-up-to-its-preexisting-conditions-promise-20140623........The Florida complaint is not the first time advocates have stepped in to tighten protections related to preexisting conditions. A few months ago, a handful of insurers in Louisiana said they would no longer accept third-party payments-including funding from Ryan White, the largest federal program to help HIV/AIDS patients-until HHS issued a regulation prohibiting these practices.
 
Bias Claims for Insurers in Coverage of H.I.V........http://www.nytimes.com/2014/05/30/business/four-insurers-accused-of-discriminating-against-people-with-hiv.html?_r=0......Karen Eldred, a spokeswoman for Cigna, told The New York Times that "the company, like many other insurers, offers an array of plans in the federal marketplaces, including some that offer more comprehensive coverage."
 
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HIV Patients Accuse Health Plans of Using Drug Costs to Discriminate........"Dr. Jose Lares-Guia, a Manhattan solo practitioner who has a large HIV practice, says some of his patients are maxing out their credit cards or going without medication."
 
By John Tozzi
July 10, 2014 5:53 AM EDT
 
http://www.businessweek.com/articles/2014-07-10/hiv-patients-say-some-obamacare-plans-drug-prices-discriminate
 
Before the Affordable Care Act, insurance companies could refuse to cover people with HIV or other costly conditions. Obamacare was supposed to end that by making insurers sell policies to all comers, regardless of preexisting conditions. Now advocates for HIV patients and others with chronic diseases say some health plans are making them bear a huge cost for life-saving medications-and that the strategy's a backdoor method of discriminating against sick people.
 
The nonprofit AIDS Institute filed a formal complaint (pdf) with the federal government May 29 over how four insurance companies structured their drug coverage in Florida's Obamacare exchange. "We found this pattern where every single [HIV/AIDS] drug for some plans was on the highest tier, including generics," says Carl Schmid, the institute's deputy executive director. Other plans cover the same drugs with a flat $25 co-pay. The group is asking the Health and Human Services Department's Office of Civil Rights to review the plans and force the insurers to lower patient costs for HIV drugs.
 
It's not just a handful of companies. A recent analysis (pdf) of 123 Obamacare plan formularies-the list of drugs an insurer will pay for-found that more than half had at least one class of medicines that required patients to pay 30 percent of the cost for all drugs in the category, generics included. People with multiple sclerosis, HIV, certain cancers, and bipolar disorder were most often asked to pay a big chunk of the price of medication, according to the report by consultant Avalere Health and funded by the pharmaceutical industry.
 
Story: Obamacare Premiums Are Going Up-Here's Why
 
Antiretroviral drugs in recent years have enabled many of the 1.15 million Americans with HIV to live normal lives with a diagnosis that was once a death sentence. Those therapies aren't cheap. Paying 40 percent or 50 percent of the retail price could cost patients more than $1,000 a month. All Obamacare plans have out-of-pocket limits that cap patients' drug spending this year at $6,350, or $12,700 for families, so insurers would eventually take over.
 
Doctors say a lot of people can't afford to pay until they reach that limit. Dr. Jose Lares-Guia, a Manhattan solo practitioner who has a large HIV practice, says some of his patients are maxing out their credit cards or going without medication. Others are traveling to Canada, Mexico, or the U.K. seeking cheaper drugs. He's taking meetings with pharma company sales reps for the first time in his life just to get access to coupons or other discounts for his patients. Insurance companies are "making the plans for people with HIV absolutely unattractive so they don't choose them," he says.
 
Insurers and pharma companies are at a standoff over drug prices. The insurance industry blames drug manufacturers for rising costsand a lack of transparency into how prices are set. Drug companies say their prices reflect the value that the medications provide, and insurers are being short-sighted when they make patients pay more for medicines that could prevent costly hospitalizations later on.
 
Story: The Crazy Way the Government Buys Billions of Dollars of Drugs The four companies named in the Florida complaint-Aetna (AET) subsidiary CoventryOne, Humana (HUM), Cigna (CI), and Preferred Medical-say their plans conform to federal guidelines. Spokespeople for Humana and Preferred Medical point out that the plan design doesn't single out HIV patients-drugs for other chronic conditions, such as cancer, multiple sclerosis, and hepatitis C are also covered in high-cost sharing tiers.
 
Health plans must be approved by state insurance regulators. But it can be difficult to detect ahead of time if a plan design discriminates against patients with a particular condition, says Sally McCarty, a former Indiana insurance commissioner and now a researcher at the Georgetown Health Policy Institute. "If an insurance company was so inclined, it would be very easy to design plans to discriminate," she says.
 
HHS declined to comment on the Florida complaint. The federal government may be keeping a closer eye on Obamacare plans next year. The Centers for Medicare and Medicaid services "intends to review plans that are outliers based on an unusually large number of drugs subject to prior authorization" or other restrictions, the agency said in a guidance (pdf) issued in March.
 
Schmid, of the AIDS Institute, fears that more plans will push the cost of medications on to patients if the government doesn't step in. "If there's no enforcement now, what are the good plans going to look like in 2015? Maybe the good plans will look to do this next year," he says.

 
 
 
 
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