How do the revised rules in the Bipartisan Budget Act of 2015 affect you and your business?
By Paula Aven Gladych
Ending insurance discrimination against the sick was a central goal of the nation’s health-care overhaul, but leading patient groups say that promise is being undermined by new barriers from insurers.
The insurance industry responds that critics are confusing legitimate cost control with bias. Some state regulators, however, say there’s reason to be concerned about policies that shift costs to patients and narrow their choices of hospitals and doctors.
With open enrollment for 2015 three months away, the Obama administration is being pressed to enforce the Affordable Care Act’s anti-discrimination provisions. Some regulations have been issued while others still are pending after more than four years.
More than 300 patient-advocacy groups recently wrote Health and Human Services Secretary Sylvia Mathews Burwell to complain about some insurer tactics that “are highly discriminatory against patients with chronic health conditions and may … violate the (law’s) nondiscrimination provisions.”
Among the groups were the AIDS Institute, the American Lung Association, Easter Seals, the Epilepsy Foundation, the Leukemia and Lymphoma Society, the National Alliance on Mental Illness, the National Kidney Foundation and United Cerebral Palsy. All supported the ACA.
Lynn Robinson, president and chief executive of Easter Seals Colorado, said she still is seeing “lots and lots of problems with denials of certain medications. I think that people with problems in behavioral health or who are on the autism spectrum are having trouble getting the therapy they need and some of the treatments they need.”
Many people, particularly those with multiple sclerosis, are being denied certain drugs or their services are capped and they are unable to get the medications they need, she added.
“Our group does have a higher cost to keep folks independent and in the community and keep them healthy,” Robinson said. “They are a much more vulnerable population.”
Coverage of expensive drugs tops their concerns.
Sharon O’Hara, executive vice president of the Colorado-Wyoming chapter of the National Multiple Sclerosis Society, said she isn’t hearing issues about drugs not being covered. Mostly, she said, people are complaining about “the cost of specialty drugs and the fact that insurance companies have required a co-insurance payment for those drugs and the co-insurance is expensive.”
Typically the copayment for a nongeneric drug runs $200 to $300. But many specialty drugs that are used to treat hemophilia, for instance, can run $30,000 a month. If patients are forced to pay a percentage of these drugs each month, O’Hara said, it can cost $2,000 to $5,000 a month until they reach their deductible.
She agreed that transparency is an issue. People don’t know what portion of their medications they will have to pay for out of pocket until they sign on with a provider – and then it is too late to switch.
“On the transparency side, we are working very deliberately with Connect for Health Colorado,” she said. “I think we have the problem solved for this open enrollment. We need a way people will know how much their drugs will cost before they purchase their plan. The insurance companies have been helpful.”
Information still lacking
Advocates nationwide also say they are disappointed by how difficult it’s proved for consumers to get a full picture of plans sold on the new insurance exchanges. Digging is often required to learn crucial details such as drugs covered, exact copayments and which doctors and hospitals are in the network.
A U.S. Health and Human Services spokeswoman said the department is preparing a formal response to the advocates and stressed that today’s level of consumer protection is far superior to what existed before President Obama’s law, when an insurance company could use any existing medical condition to deny coverage.
The law also takes away some of the motivation insurers have for chasing healthy patients. Those attracting a healthy population must pay into a pool that will reimburse plans with a higher share of patients with health problems. However, that backstop is under attack from congressional Republicans as an insurer “bailout.”
Compounding the uncertainty is that Washington and the states now share responsibility for policing health plans sold to individuals.
Julie Reifkin, executive director of the Colorado Cross-Disability Coalition, said “insurance companies are still allowed to discriminate in many ways with what they will and won’t cover. It might not be discrimination per se, but if we only cover $2,000 in medical equipment, that is not going to work for people in wheelchairs.”
Reifkin said she hasn’t seen anyone denied insurance because of a disability or pre-existing condition but “that doesn’t mean it isn’t happening.” Her organization works more with the public health system, such as Medicaid, than with the private system.
“When someone has to buy insurance, if they are not eligible for Medicaid, they have to buy insurance that is not doing any good because of what they cover,” she said. “That isn’t discrimination in the classic sense of the word.”
Basic level of protection
Although the federal government is running insurance markets in 36 states, state regulators are still in charge of consumer protection. A few states refuse to enforce any aspect of the law.
Kreidler said the federal government should establish a basic level of protection that states can build on. “We’re kind of piecemealing it right now,” he said.
Also worrisome are the narrow networks of hospitals and doctors that insurers are using to keep premiums down. Healthy people generally shop for lower premiums, while people with health problems look for access to specialists and the best hospitals.
Before Obama’s overhaul, insurance plans sold on the individual market could exclude prescription coverage. Now the debate is over what’s fair to charge patients.
The insurance industry trade group America’s Health Insurance Plans says there’s no discrimination because patients have many options on the insurance exchanges. Gold and platinum plans feature lower cost-sharing but have higher premiums. Standard silver plans generally require patients to pay a greater share of medical bills, but some have fairly robust drug coverage.
“There are plans on the exchanges that are right for people who have these health conditions,” said Brendan Buck, a spokesman for the group.
For 2015, the administration says it will identify plans that require unusually high patient cost-sharing in states where Washington is running the exchange. Insurers may get an opportunity to make changes. Regulators will collect and analyze data on insurers’ networks.
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The Associated Press contributed to this report.