GO
Loading...

Bias claims for insurers in coverage of H.I.V.

Pedestrians walk past the entrance to the Cigna Corp. headquarters in Philadelphia, Pennsylvania.
Bradley C. Bower | Bloomberg | Getty Images
Pedestrians walk past the entrance to the Cigna Corp. headquarters in Philadelphia, Pennsylvania.

Health care advocates said on Thursday that four insurers offering plans in the new federal marketplace discriminated against people with H.I.V. or AIDS by requiring them to pay high out-of-pocket costs for drugs to treat H.I.V., including generic medications.

Two groups, the AIDS Institute and the National Health Law Program, filed a complaint on Thursday with the Department of Health and Human Services' Office for Civil Rights, saying the insurers had violated a provision in the new health care law that prohibits discriminating against consumers because of their medical conditions. They said the insurers had subjected people infected with H.I.V. to restrictions on medications that most patients take daily to keep the virus in check.

Read More7 in 10 say Obamacare had bad or zero impact on US

"This practice has no rational reason other than to drive people with H.I.V. and AIDS away from their plans," Wayne Turner, a staff lawyer with the National Health Law Program, said in a conference call with reporters.

The complaint asserts that the four insurers — CoventryOne, Cigna, Humana and Preferred Medical Plan — placed H.I.V. drugs on the highest payment tier for midlevel, or silver, plans on the federal health insurance exchange in Florida.

CoventryOne, for example, placed every H.I.V. drug, including generics, on the most restrictive tier, which meant consumers were required to exhaust a $1,000 deductible and were then asked to contribute 40 percent toward the cost of their drugs, the groups said. Similarly, Humana requires that members spend their $1,500 deductible and then contribute 50 percent, they said. Many of the plans, the groups said, also placed other requirements on the drugs, like advance authorization by a doctor or a limit of a 30-day supply.

Read MoreHackers are coming after your medical records

Representatives for all four insurers said their plans' H.I.V. drug coverage was in line with accepted medical practice and met requirements for coverage.

Karen Eldred, a spokeswoman for Cigna, noted that the company, like many other insurers, offers an array of plans in the federal marketplaces, including some that offer more comprehensive coverage.

A spokesman for Humana, Alex Kepnes, also noted that drugs for other diseases, like rheumatoid arthritis and multiple sclerosis, were also on a high payment tier.

Insurers have been asking consumers to pay more for the most expensive so-called specialty drugs, a trend that accelerated in the new marketplaces as insurers competed fiercely to keep premiums low. Patients with serious conditions, like cancer or rheumatoid arthritis, are finding that their pharmacy bills are skyrocketing.

Read MoreAs US honorsveterans, problems pile up at the VA

Advocates for people with other serious — and costly — medical conditions are likely to be watching this case closely, said Jennifer Kates, director of global health and H.I.V. policy at the Kaiser Family Foundation. If the federal office were to side with the patient advocates, "it would have broader implications because it would say this couldn't happen for those with diabetes, or any other kind of condition," she said.

The health care groups said what made this case different was that not every insurer placed such across-the-board restrictions on H.I.V. drugs.

"What is unique here is that it's every single drug, no matter whether it is generic or not," said Carl Schmid, deputy executive director of the AIDS Institute. "Other plans don't do this for H.I.V., and that's why we're proving that it's discrimination."

Other insurers offering silver plans in Florida's marketplace, including Florida Blue, Ambetter and Molina Healthcare, offered more generous coverage, with most out-of-pocket costs ranging from $10 to $25 a prescription, often after meeting a deductible, the groups said.

Mr. Schmid said many people with H.I.V. and AIDS welcomed the arrival of the new health care act because it meant they would have access to insurance after years of being shut out; before the law took effect, insurers could deny coverage to people with existing medical conditions like H.I.V. infection.

More from the New York Times:

U.S.Strategy to Fight Terrorism Increasingly UsesProxies
SteveBallmer Agrees to Buy Clippers for $2 Billion
DoctorShortage Is Cited in Delays at V.A. Hospitals

But he said some patients were shocked when, newly covered, they were asked to pay pharmacy bills of up to $1,000 a month, in addition to the premiums they were paying. Some popular drugs, like Truvada, sell for $1,500 a month. Another therapy, Atripla, costs $2,400 a month, according to recent prices posted on the website of the National Institutes for Health.

Under the new health care law, out-of-pocket costs cannot exceed $6,350 a year, and some people with H.I.V. and AIDS can receive assistance for out-of-pocket costs through the federal Ryan White Program. But help is limited to those whose income falls below certain levels, which vary by state, and the federal funding must be appropriated each year by Congress.

Of the more than 1.1 million people living with H.I.V. or AIDS in the United States, about 400,000 are receiving treatment, and of those, about 23,000 are uninsured and eligible for coverage in the new marketplaces, according to a recent study by the Kaiser Family Foundation. Some in the exchanges may also have been previously covered through individual plans, and thousands more could begin receiving treatment now that they have insurance.

But although these patents' numbers are small, insurers have most likely taken note of the costs associated with treating H.I.V. patients: in a recent study of the first two months of prescription-drug use by people enrolled in new exchange plans, H.I.V. drugs accounted for 55 percent of all specialty drug claims, compared to 21 percent of claims made through employer plans during the same period.

Read MoreUS FDA questions use of aspirin to prevent first heart attack

Mr. Turner said the groups took action partly to ensure that other plans did not follow in the footsteps of the insurers in the complaint.

"What we may be seeing is a race to the bottom," he said. "Plans don't want to be the preferred plan for people with H.I.V. and AIDS."

Contact Health Insurance

  • CNBC NEWSLETTERS

    Get the best of CNBC in your inbox

    › Learn More