Patient advocates say too many health plans are requiring patients with HIV to spend large sums on their medications, potentially raising concerns about discrimination.
In a report provided this month to the Star Tribune, researchers from Harvard Law School and the Minnesota AIDS Project highlight health plan options on the state’s MNsure exchange that feature high degrees of “cost-sharing” for medications used by people with HIV.
The report, which also looked at hepatitis C medications, is one of the latest to examine how health insurers in different states are covering HIV treatments on new government-run insurance exchanges.
“I think they know the impact that putting high cost-sharing on these medications has to deter people,” said Carmel Shachar, an attorney at Harvard’s Center for Health Law and Policy Innovation. “We do think the pattern of tiering is suggestive of discrimination.”
Insurers deny any discrimination, and say the real issue is that drugs are expensive. The cost-sharing features of their health plans are used with medications for all conditions, insurers say, not just HIV/AIDS.
“We would all like to make the super expensive drugs less costly, but so far that hasn’t happened,” said Jim Schowalter of the Minnesota Council of Health Plans, a trade group for health insurers. “Premiums or coinsurance or deductibles will look and feel expensive, because the drugs are so expensive.”
At the end of 2014, an estimated 8,000 people were living in Minnesota with HIV/AIDS, according to the state health department. At the time, 590 people were living with HIV and hepatitis C.
Arguments between patient advocates and health insurers about cost-sharing often revolve around how medications are assigned to different “tiers” within the health plan’s “formulary” of covered drugs. The amount a patient must pay depends on the formulary tier where the drug lands.
The new report in Minnesota analyzed 21 “silver” health plans available to individuals buying nongroup coverage on the state’s MNsure health insurance exchange.
The plans are sold by four health insurers — Eagan-based Blue Cross and Blue Shield of Minnesota, Bloomington-based HealthPartners, Minnetonka-based Medica and Minneapolis-based UCare — and the report found insurers covered almost all of the roughly two dozen medications surveyed.
While Minnesota insurers provide coverage for most HIV medications, the report found that most health plans charge patients “coinsurance,” meaning a percentage of the drug’s total cost within certain limits.
In eight of 21 cases, Minnesota health insurers imposed coinsurance fees of 40 percent or more, according to the report.
“When a plan offers all of its medication on 40 percent coinsurance, they know that they’re making themselves look very unattractive to people living with HIV,” Shachar said in an interview.
Schowalter of the Minnesota Council of Health Plans, however, argued that coinsurance is simply another way that health plans split expenses with patients.
When those fees are high, he said, they often bring trade-offs like lower premiums or deductibles.
“I think that there are many different insurance options that are offered to people, so people can pick what’s best for them,” Schowalter said.
The federal health law requires that all silver-grade plans provide a similar level of coverage, he said, but allows for variation in exactly how insurers set premiums and cost-sharing features.
That’s true, said Shachar of Harvard, but insurers can hit the overall target for richness of coverage by giving some patients better deals than others.
“We believe that the cost-sharing structures offered by the [Minnesota health plans] are egregious enough to justify a complaint to the federal Office of Civil Rights at the Department of Health & Human Services,” Shachar wrote in an e-mail. The Harvard group expects to have a complaint for local advocates to review and sign onto by summer, she said.
In May 2014, patient advocates complained to the federal government about four health insurers in Florida that placed all HIV medications on either the “Tier 5” or a “specialty drug tier,” where coinsurance payments of 40 percent or 50 percent applied.
A 2015 study
In January 2015, a different group of Harvard researchers published a study in the New England Journal of Medicine about “adverse tiering,” in which health insurers placed a key class of HIV medications in a formulary tier with coinsurance fees of 30 percent or more. The study estimated that a person with HIV would pay more than $3,000 for treatment annually in an adverse-tiering plan than another option.
At the Minnesota AIDS Project, counselors see many patients enroll in “gold” plans — rather than the silver plans studied in the report — because they tend to feature lower out-of-pocket costs for medications, said Lauren Piper, the group’s benefits counseling coordinator.
To some degree, Minnesota patients with HIV are insulated from high out-of-pocket costs with medications by a federally funded program that covers about 2,500 people.
Piper said it’s difficult for her group to say whether there’s discrimination by health insurers for people with HIV or hepatitis C, because the group hasn’t analyzed how health plans handle other chronic conditions.
“It is clear, however, that Minnesota insurers are structuring their plans in ways to dissuade at least one subpopulation of expensive consumers, i.e. people living with HIV/AIDS and HCV, from enrolling,” Piper wrote in an e-mail.