Already set to charge higher health insurance premiums next year, most of the companies that provide plans via the Affordable Care Act (ACA) marketplace in Georgia are also trying to sidestep one of the tenets of the ACA in the coverage they offer to people living with HIV/AIDS, according to new data from the AIDS Research Consortium of Atlanta (ARCA).

ARCA analyzed all of the health insurance silver-tier plans available through the ACA, which are the most commonly used plans and are intended to be the middle ground between low-premium, low-coverage bronze plans and more costly and comprehensive gold and platinum options. Researchers found that the four insurance providers in Georgia — Blue Cross Blue Shield of Georgia, Alliant, Ambetter and Kaiser — placed most, if not all, of their HIV/AIDS medications on a tier that requires the most out-of-pocket contribution from consumers.

“A lot of insurers say that they’re not discriminating because they’re not changing their premium based on a pre-existing condition, which is what they would have done before the Affordable Care Act,” said Callan Wells, who led the analysis of ACA silver plans for ARCA.

“What we found is that one of the ways in which they are still causing higher costs for people who do have HIV or AIDS is they’re charging higher prices on the back-end,” Wells said. “The drugs that they are using — the ones that are recommended — the insurers, specifically Blue Cross Blue Shield, have put those drugs typically on the highest tier of drugs.”

Premium increase on the way

There is no standard for structuring coverage of medications, with each insurance company developing its own tiers for drugs and how much coverage is included in each of those tiers. Most commonly, drug companies place generic drugs with a low co-pay on the bottom tier, and preferred drugs that have a flat co-pay on the second tier; non-preferred medications with higher out-of-pocket costs are on the third tier, while specialty drugs that have a high, variable co-insurance obligation are placed on the highest tier.

Blue Cross Blue Shield, Alliant and Kaiser placed all of their HIV medications on the highest tier, requiring between a 40-50 percent co-insurance payment by the consumer each month.

“What they do when they put all of the drugs on the very highest tier is, in essence, discriminate against people with HIV by putting all of the their drugs out of reach,” said Dr. Melanie Thompson, principal investigator at ARCA.

In September, Georgia insurance officials approved a proposal from all four insurance providers to increase the cost of premiums by more than 50 percent, meaning some 2018 plans require consumers to pay up to $400 per month just to maintain coverage.

“HIV drugs are often hundreds of dollars for a 30-day supply, and so even if that drug was $500, that’s still leaving a huge chunk that the consumer has to pay,” Wells said. “Adding hundreds of dollars for the cost of the drug on top of increased premiums, we believe that it would become incredibly unaffordable, which is a way of still discriminating.”

ARCA conducted the review of ACA plans in Georgia to help folks navigate the federal marketplace, and has provided its raw data to ACA navigators at the Health Initiative and at Ryan White clinics. But the analysis was also a collaboration with the Harvard Law School’s Center for Health Law and Policy Innovation, which is using data from 16 states to try to improve access to medications.

Multiple civil rights complaints possible

The placement of HIV medications in the highest pricing tiers could subject insurance providers to multiple civil rights complaints with the office of civil rights at the U.S. Department of Health & Human Services, which oversees the ACA’s non-discrimination provision, Thompson said.

In 2016, ARCA and the Harvard center filed a complaint regarding HIV medication being restricted to the highest tiers against Humana and Cigna, both of which no longer participate in the Georgia ACA marketplace. That complaint included comparing whether drugs for other chronic conditions such as rheumatoid arthritis were placed exclusively in the most expensive tiers.

“Some of the things that go into the decision to file a civil rights complaint are not only how an insurer treats an HIV drug, but how other insurers treat those same drugs,” Thompson said. “For example, one of the insurers puts all of the drugs on the highest tier, another insurer like Ambetter has drugs on multiple tiers, at lower costs.”

Blue Cross Blue Shield, which pulled out of the metro Atlanta marketplace and is the only ACA provider in south Georgia and other rural parts of the state, not only placed all of its HIV medications on the highest tier, but also does not include common HIV treatments in any of its coverage. Kaiser, one of the two providers covering Atlanta, also put all of HIV drugs in tier four and five, with most having a 50 percent co-insurance payment.
Ambetter, the other provider offering plans in metro Atlanta, stood out in ARCA’s analysis for the affordability of its drug prices, although Thompson said it’s important to remember that the value of an insurance policy is not solely determined by drug coverage.
“Ambetter does spread out the HIV drugs onto a number of different tiers, and they have more drugs that have a flat co-pay,” Thompson said. “Some common drugs are actually on a much more affordable tier with a $50 flat co-pay, and their higher-tier specialty drugs, which is pretty much the rest of the HIV medications, either have a 20 percent co-insurance, or no charge after you meet the deductible.”

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