The Obama administration will investigate health insurance companies' prescription drug coverage and other benefits after becoming aware of "discriminatory benefit designs" that discourage people with certain conditions from enrolling in health plans, according to the New York Times.
These conditions are likely to include bipolar disorder, diabetes, HIV/AIDS, rheumatoid arthritis and schizophrenia. The Patient Protection and Affordable Care Act prohibits insurers from excluding applicants for coverage or charging higher premiums because of an individual's pre-existing condition or disability.
The Obama administration said it would begin investigating discrimination allegations after advocates for people with HIV/AIDS and other illnesses complained of limited access to benefits. According to the NYT, CMS said it will focus on insurers in the federal marketplace.
Insurers with health plans that exclude all drugs needed to treat a certain condition or restrict access to such drugs by imposing high co-payments or requiring prior authorization are considered discriminatory. Additionally, if insurers place most or all of the drugs required to treat a certain condition into the highest-cost tiers, that plan design also discriminates against people with such conditions or discourages enrollment. Lastly, age limits are discriminatory when they are attached to services that are clinically effective at all ages, according to NYT.
Some health plans require patients to pay 40 or 50 percent of the costs of drugs to treat bipolar disorder and schizophrenia. According to the article, Humana required patients to pay 50 percent for some of the more expensive drugs used to treat HIV prior to reaching an agreement last week with the Florida insurance commissioner, in which patients will only be required to pay a 10 percent co-payment for the medication. Similar agreements have been made in Florida with Cigna and Coventry Health Care, a unit of Aetna.
According to the article, the National Association of Insurance Commissioners is drafting a law that could serve as a model for states to regulate their networks.