Two health organizations filed a complaint with federal health officials Thursday alleging some Florida insurance companies are violating the Affordable Care Act by structuring their insurance plans in a way that discourage consumers with HIV and AIDS from choosing those plans.
The National Health Law Program and The AIDS Institute of Tampa said four insurance companies offering plans in Florida through the federal online exchange required HIV and AIDS patients to pay a percentage of their often expensive drugs instead of a flat co-pay.
Instead of paying $10 at the pharmacy, the plans require patients to pay 40 to 50 percent of the cost of their drug, which could run into the thousands of dollars, according to the complaint. Health experts say the case could have national implications.
The groups also alleged the plans charged high up-front costs and require unwieldy prior authorizations. The complaint, filed with the Office for Civil Rights at the Department of Health and Human Services, asks the agency to investigate the Florida plans offered by CoventryOne, Cigna, Humana and Preferred Medical and require the insurance companies to take corrective actions if necessary.
Federal health officials said they are reviewing the complaint.
The report alleges that CoventryOne requires consumers to pay 40 percent co-insurance for the cost of all HIV drugs, including generics, after a $1,000 deductible. "That would be about $1,000 per month per drug in most instances. What patient could afford that?" said Carl Schmid, deputy executive director of The AIDS Institute.
Health advocates warn high costs cause patients to skip doses or go off their medications altogether, causing serious health complications.
Cigna, Humana and Coventry said in separate statements that their plans follow the latest HHS guidelines, cover all medically necessary HIV drugs and offer a variety of options so consumers can pick a plan that best meets their health needs. Preferred Medical did not immediately return a call seeking comment.
South Florida attorney Vicki Tucci said she's trying to help more than 30 clients with HIV and AIDS to get off Humana, Coventry and other plans and switch to insurer Florida Blue, which advocates said offers better coverage for those conditions.
"They go to the pharmacy and find their drug is not covered and they can't afford them. There's no way," said Tucci.
Tucci is working with advocacy groups that would pay the cost of medication while those with HIV and AIDS are without insurance until the next open enrollment period later this year.
Even before the Affordable Care Act took effect, insurers had increasingly begun requiring patients to pay a percentage of their drug costs instead of a flat co-pay, but experts say patients often spend more for their prescriptions in plans offered under the health law because of the co-insurance.
The organizations said they didn't know how many HIV and AIDS patients had purchased health plans from companies being targeted in the complaint. But a study from the nonpartisan Kaiser Family Foundation estimates about 23,000 uninsured people in the U.S. being treated for HIV and AIDS would be eligible for coverage through the online exchange.
Although the complaint filed Thursday specifically addresses HIV and AIDS, other health advocates have expressed concerns about high co-insurance for others with serious illnesses, including cancer and rheumatoid arthritis, which require expensive drugs.
The Leukemia & Lymphoma Society found exchange plans in several states that charged patients with blood cancer as much as 50 percent co-insurance rates. The National Multiple Sclerosis Society recently addressed the issue at a conference in Washington.
Health advocates are quick to point out that before the Affordable Care Act, many of their patients struggled to have health insurance at all. The law forbids insurers from discriminating against those with pre-existing conditions.
The law also bans insurers from charging an individual more than $6,350 in out-of pocket costs a year and no more than $12,700 for a family policy. But patients advocates warn those with serious illnesses could pay their entire out-of-pocket cap before their insurance kicks in any money.