Insurers Are Steering Some Patients Away

Under the Affordable Care Act, insurers can no longer deny people coverage based on their health status. But nobody said anything about charging sick people more for their drugs.

A new report out Wednesday from Avalere found if you buy insurance on the exchanges created under Obamacare and need access to HIV medications, you may have to pay a pretty penny.

Lead researcher Caroline Pearson said more than half of mid-range (Silver) plans on the exchanges don’t cover the 10 most commonly prescribed HIV regimens. Her work suggests insurers are trying to keep sick people away.

“If you are a health plan and you are competing against other plans on the market, if you have a lot of HIV patients enrolled in your plan, you are losing money,” she said. “So there are really clear business incentives here.”

To Pearson, this is how the new insurance game is played under the ACA — design plans with high out-of-pocket costs that encourage expensive patients to knock on someone else’s door.

Perhaps the clearest example, said Harvard’s Robert Greenwald, is how insurers are switching consumers from a flat copay fee to co-insurance, where a person pays a percentage of their medication.

“The insurers are saying, ‘Oh, we can’t keep people off, we can’t charge people higher premiums. I’ve got it. Let’s change the way we do co-insurance,’” he said.

For example, Greenwald said some consumers went from a once-a-month $50 copay to a once-a-month $600 co-insurance payment for the same prescription drug. And while consumers benefit from out-of-pocket limits, he said consumers must come up with more cash up front.

Greenwald considers these practices a violation of new civil rights protections under the ACA. But John Bertko, an insurance actuary with 40 years in the business, said these practices are less about discriminating and more about getting good deals from pharmaceutical firms.

Remember, said Bertko, every health plan must offer some HIV drugs, but not all of them.

“The question really is, ‘Do people really need every one of those drugs, and can plans be able to bargain a bit?’” he said.

Bertko said limiting access to drugs is one of the few ways insurers can negotiate with drug companies. He said if a consumer really needs access to a certain drug, they should appeal. Most times, he said, the consumer will win.

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