The Centers for Medicaid & Medicare Services (CMS) and state regulators are taking a closer look at proposed 2016 health insurance policies in an attempt to rid plans of what the Affordable Care Act terms “discriminatory benefits.” For example, pharmacy benefits within health plans have been found discriminatory when all the drugs in a certain class, such as HIV/AIDS drugs, are placed on the specialty pharmacy tier.
In what could be a sign of coming trend, the Florida Insurance Commissioner, last year, acted on a complaint from the AIDS Institute and The National Health Law Program (NHeLP) that four carriers “charge[d] inordinately high co-payments and co-insurance for medications used in the treatment of HIV and AIDS.” The commissioner required the insurers to change their drug coverage during the benefit year, forcing the insurers, that had not priced their products for the more generous drug benefit, to absorb the cost.
Mike Adelberg, senior director at FaegreBD Consulting, commented on the Florida case and its implications for 2016 in a recent issue of Inside Health Insurance Exchanges.
“The opinion of the commissioner was that the plans were designed to encourage people with HIV/AIDS to select a different carrier,” Adelberg said. “While the drugs can be expensive, the cost of acute care for those patients can be substantial.”
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