The Obama administration will investigate prescription drug coverage and other benefits offered by health insurance companies to check any discrimination against people with AIDS, mental illness, diabetes or other costly chronic conditions. The administration had come know that some insurers discouraged people from enrolling due to age or medical conditions.
The administration officials said that a health plan could be engaging in unlawful discrimination if its list of approved drugs excluded all medicines needed to treat a particular condition, or if it restricted access to such drugs by charging large co-payments or requiring prior authorization.
The Centers for Medicare and Medicaid Services said it would focus on companies in the federal insurance marketplace. For each health plan, it said, it will try to determine the "estimated out-of-pocket costs associated with standard treatment protocols for specific medical conditions using nationally recognized clinical guidelines." The conditions, it said, are likely to include bipolar disorder, diabetes, H.I.V., rheumatoid arthritis and schizophrenia.
The Affordable Care Act dictates that insurers must accept all applicants for coverage and cannot charge higher premiums because of a person's pre-existing conditions or disabilities. Advocates for people with H.I.V./AIDS and certain other illnesses found that insurers were unduly limiting access to benefits.
Kevin M. McCarty, the Florida insurance commissioner, last week reached an agreement with Humana so that the amount paid by the patient for H.I.V. drugs was significantly reduced. Earlier, patients paid up to 50% and now would have to pay only 10%.
Thomas T. Noland Jr., a senior vice president of Humana, said, "Florida has a unique law providing insurance-related protections to individuals with H.I.V./AIDS." Humana denied that it had violated the law, but Mr. Noland said, "We understand the affordability challenges facing those with H.I.V./AIDS because of the relatively high cost of their specialty medications."
Insurers, also known as insurance issuers, typically classify drugs into three or more categories with different levels of co-payments and cost-sharing. "If an issuer places most or all drugs that treat a specific condition on the highest-cost tiers, that plan design effectively discriminates against, or discourages enrollment by, individuals who have those chronic conditions," said the administration. The administration also said, "age limits are discriminatory when applied to services that have been found clinically effective at all ages." It said it would challenge restrictions on benefits if they were "not based on clinically indicated, reasonable medical management practices." Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, an advocacy group, said he welcomed the new standards.
"When a doctor follows recommended treatment guidelines," Mr. Sperling, a lobbyist at the National Alliance on Mental Illness, an advocacy group, said, "the cost-sharing should not be so burdensome that it discourages patients from adhering to the treatment." In some health plans, he said, patients are routinely required to pay 40 percent to 50 percent of the costs for drugs to treat bipolar disorder and schizophrenia.
New rules requiring insurers to improve the accuracy of publications listing their doctors and hospitals were put in place by the administration. Consumers have found that these directories are full of errors and often include doctors who are not affiliated with the insurers' health plans.