The Affordable Care Act (ACA) prohibits insurance companies from denying coverage to someone because of a pre-existing condition.
However, that doesn’t necessarily mean the coverage that they provide is affordable or comprehensive, especially for people attempting to manage chronic conditions.
Critics say the insurance companies aren’t covering treatments equally or being clear about what medications are covered in certain plans.
HIV Treatments Cost Patients More
A study from Avalere found that 16 percent of mid-level (silver) plans from the ACA marketplace provide the top HIV drugs to their insured clients for less than $100 per month.
Meanwhile, 28 percent of the plans provide coverage for seven to nine medications at a cost of less than $200 a month. A whopping 57 percent of marketplace plans cover fewer than seven medications with more than $200 in out-of-pocket costs to patients.
Caroline Pearson, senior vice president at Avalere, said this is a major concern because it ultimately affects patient health.
“Ensuring individuals living with HIV have affordable access to their medications is critical both for maintaining the health of the patient but also for improving public health by limiting disease transmission,” she said in a statement on the healthcare consulting company’s site.
Brian Hujdich, executive director of HealthHIV, said the Avalere assessment reveals the prevalence of cost-sharing arrangements on ACA plans that may bust patients’ budgets.
He offered the story of a man named Gerald. He says it’s emblematic of the cost-sharing problems facing many people with HIV.
Gerald lost his employer coverage when he switched jobs. On his insurance plan under the ACA, he spends more than $5,000 a year for out-of-pocket treatment because of high coinsurance requirements.
Including the $360 he pays per month in premiums, Gerald spends 13 percent of his annual earnings on healthcare, far higher than the 9.5 percent limit that the ACA defines as affordable for employer-sponsored coverage, Hujdich says.
“Ever higher cost-sharing isn't the only thing patients need to look out for when evaluating plan options,” Hujdich told Healthline. “Insurers also use access-restricting tactics like ‘step therapy,’ which forces patients to fail to respond to less expensive medicines before they can upgrade to newer drugs, and ‘prior authorization,’ which requires patients and their doctors to battle insurance companies for permission to use a particular, physician-recommended therapy.”
Chris Lokken, an employee benefit consultant with Johnson Insurance in Eau Claire, Wisconsin, said insurers are trying to manage financial risks by preventing patients from immediately seeking more expensive therapies.
“This is not necessarily targeted at one medical condition,” he told Healthline.
Cancer Patients Not Immune from Loopholes
The American Cancer Society’s Cancer Action Network recently updated their findings of transparency problems with insurance marketplaces under the ACA in six states.
Specifically looking at coverage and cost-sharing requirements, it found improvements from 2014, but that “significant barriers remain for cancer patients.”
They found limited coverage for newer oral chemotherapy drugs, unclear coverage on intravenous medications, cost-sharing structures that didn’t match those advertised on websites, and plans that place most or all of oral chemotherapy costs on the highest tiers of coverage.
“Across all six states, between 73 and 100 percent of silver plans use coinsurance on the highest cost-sharing tier, meaning consumers using cancer drugs must pay a percentage of the cost of their drugs rather than a flat copayment,” researchers said in their report released Thursday.
This, researchers said, equates to discrimination. To prevent that, they recommended several policy changes, including monitoring practices for evidence of discrimination for people with high-cost conditions, using copays instead of prescription drug coinsurance, and standardizing cost-sharing and coverage limits.
Until these policies are fixed legislatively, Lokken said consumers can protect themselves by keeping experts in their corner.
Just as it would be foolish to enter a courtroom without the guidance of a lawyer, Lokken recommends people seek the assistance of an insurance agent when navigating insurance coverage, especially those managing complicated medical conditions.
“When you get into the fine print, you need to be proactive on the front end and ask questions,” he said. “In the end, some of this is like trying to catch Jell-O.”