By Louise Radnofsky
Patient advocacy groups are using antidiscrimination provisions
in the health-care law as the basis of a complaint against insurers
they say are trying to avoid covering consumers with HIV and AIDS,
in one of the first cases of its kind.
The National Health Law Program and the AIDS Institute submitted
a complaint to the Department of Health and Human Services' Office
of Civil Rights Thursday morning accusing four health insurers
selling individual plans in Florida of discriminating against
consumers with HIV in the way they designed their insurance
benefits. The complaint names Coventry Health Care Inc., a unit of
Aetna Inc., Cigna Corp., Humana Inc. and Preferred Medical, a plan
based in Coral Gables, Fla.
The complaint says the four insurers put every HIV drug, even
older generics, in the highest tier in their drug formularies,
requiring patients to pay as much as 50% of the cost
themselves.
HIV advocacy organizations have said the issue isn't specific to
Florida and they believe a decision would influence plans across
the country.
The health law bars insurers from charging customers more based
on their medical history when it comes to setting premiums. The
Wall Street Journal reported in December that HIV organizations
believed some health insurers had found other ways to discourage
people infected with HIV from signing up for their plans, such as
requiring higher copayments for HIV drugs than they would for other
prescriptions.
The two patient advocacy organizations are trying to challenge
that practice by using another provision in the health law that
bars any health program that receives federal funds from
discriminating on the basis of "race, color, national origin, sex,
age, or disability."
Wayne Turner, a staff attorney for the National Health Law
Program, said the complaint appeared to be the first one that drew
on the antidiscrimination provision to go after an insurance plan's
benefit design.
A handful of different complaints filed with the Office of Civil
Rights have cited the antidiscrimination provision to challenge
other decisions by health insurers.
Alex Kepnes, a spokesman for Humana, and Karen Eldred, a
spokeswoman for Cigna, both noted that their company's plans did
cover HIV drugs.
Mr. Kepnes said Humana covered all HIV drugs except brand names
when generics were available, and that the insurer considered most
of them to be specialty drugs covered in the same category as
treatments for conditions such as rheumatoid arthritis, multiple
sclerosis and growth hormone disorders.
He pointed out that consumers wouldn't have to pay anything when
filling their prescriptions after they had hit their maximum on
out-of-pocket costs. Under the health law, no plans can have an
out-of-pocket maximum higher than $6,350 for 2014.
Ms. Eldred said that Cigna covered all HIV drugs that were
recognized as medically necessary and also offered consumers with
HIV support managing their condition from a team of nurses,
pharmacists and therapy support coordinators.
Officials for Coventry and Preferred Medical didn't immediately
respond to requests for comment.
Melinda Beck contributed to this article.
Write to Louise Radnofsky at louise.radnofsky@wsj.com
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