August 12, 2015 at 4:49 pm EST | by Lou Chibbaro Jr.
D.C. intervenes in HIV drug bias case
Mila Kofman, gay news, Washington Blade, health insurance

Executive Director of the D.C. Health Benefit Exchange Mila Kofman (Image courtesy C-Span)

At least three D.C. government agencies “took aggressive steps” earlier this year to stop a health insurance company from discriminating against people with HIV by forcing them to pay excessively high co-payments for their life-saving prescription drugs.

According to Mila Kofman, executive director of the D.C. Health Benefit Exchange, which operates the city’s version of the Obamacare health insurance program, an insurer she declined to identify agreed to drop a practice federal regulators have called “adverse tiering” of drug co-insurance payments.

Kofman said a team of officials with her agency; the D.C. Department of Health; and the D.C. Department of Insurance, Securities and Banking initiated “extensive discussions with this one particular insurance company” after learning the company was placing HIV medications in its highest tier of co-payments for patients.

When asked why she was reluctant to identify the insurer, Kofman said her objective was to persuade the company to end a practice that AIDS advocacy groups have said is aimed at evading the Obamacare law’s strict ban on denying insurance to people based on a pre-existing condition.

Advocacy groups, including the Florida and D.C.-based AIDS Institute, have said a growing number of insurers have sought to discourage people with HIV from purchasing their health insurance policies by charging prohibitively high co-payments for AIDS-related drugs.

“It could have happened with any insurer,” Kofman said. “So I’m not sure naming a particular company is helpful because they changed their policy,” she told the Washington Blade.

“They also reviewed their formulary and eventually changed their formulary,” she added, referring to a process health insurance companies use to determine how much of the cost of a drug the patient should pay under their insurance plan.

“And so what they did was they moved the HIV medications to the generic or the preferred tiers. So anything that’s not injectable they moved to the tiers that would result in low co-payments and the lowest co-insurance for patients,” Kofman said.

She said an investigation by three agencies found that the company in question applied its “adverse tiering” policy only to policies sold to individuals and families but not for group policies sold mostly to employers.

As of 2014, when the company in question reportedly began its adverse tiering policy for AIDS drugs, there were just three insurers enrolled in the D.C. Health Benefit Exchange that provided health plans for individuals — CareFirst, Kaiser Permanente and Aetna.

According to a June 11, 2015 article in Health Affairs Blog, which is considered an authoritative journal on U.S. health policy issues, a D.C. man with HIV reported being hit with excessively high co-insurance payments under a plan he had with Aetna.

“Roger Thompson (not his real name), a middle-aged, HIV-positive freelance artist who lives in Washington, D.C., experienced adverse tiering when he enrolled in an Aetna plan on the D.C. Health Link, the D.C. health insurance marketplace, in 2014,” the article states.

“To his surprise, when he enrolled in an Aetna plan, he was told HIV medications would cost over $20,000 annually,” according to the article. “Unable to afford this, he opted not to take HIV medications for four months. Ultimately he traveled to Canada to purchase medications at a significantly lower cost to avoid ending up sick and in the hospital,” the article says.

“Unsurprisingly, Roger decided to change plans in 2015,” it says.

A spokesperson for Aetna couldn’t immediately be reached for comment.

The Health Affairs Blog article, which reports on a study of adverse tiering practices published in the New England Journal of Medicine, says that in addition to being harmful to consumers, the practice puts insurers that don’t engage in it at a competitive disadvantage.

It notes that people with serious medical conditions that require expensive drugs to treat who drop out of health plans from insurers who engage in adverse tiering often flock to the insurers that don’t engage in that practice, forcing them to absorb the higher drug costs.

“As a result, adverse tiering is increasing in popularity among insurers,” the article says.

Kofman is calling on D.C. residents who believe they may be facing adverse tiering policies under their health insurance policies to contact the D.C. Health Benefit Exchange.

“If there is discrimination we’re in a good position to review the policy and if there is discrimination we can address it,” she said. “And no consumer should be by themselves and try to figure this out by themselves. We advocate for them and for their interests.”

Lou Chibbaro Jr. has reported on the LGBT civil rights movement and the LGBT community for more than 30 years, beginning as a freelance writer and later as a staff reporter and currently as Senior News Reporter for the Washington Blade. He has chronicled LGBT-related developments as they have touched on a wide range of social, religious, and governmental institutions, including the White House, Congress, the U.S. Supreme Court, the military, local and national law enforcement agencies and the Catholic Church. Chibbaro has reported on LGBT issues and LGBT participation in local and national elections since 1976. He has covered the AIDS epidemic since it first surfaced in the early 1980s. Follow Lou

2 Comments
  • The other option is to import generic versions (licensed by the pharmaceuticals for manufacture and sale abroad) of the drugs from overseas at pennies on the dollar.

  • In the mid-90s, I was covered by the Johns Hopkins Health Plan. JH sold the health plan to Aetna, who assured me that I could see all the doctors I formerly saw with the JH plan (I have an inherited genetic eye disease that needs to be checked periodically). To see the doctors without insurance would have cost me $300 (or more) per visit – the only cure for the disease I have is corneal transplant, and the surgeon needs to be involved for at least 2 years prior to surgery.

    I soon found out that Aetna would NOT allow me to see the doctors I wanted, and suggested two doctors in Baltimore County. Upon inquiry, the doctors offices had never heard of the disease, let alone treated anyone with it. I waited until the next open season to get away from Aetna and to get insurance that allowed me to see the doctors who had treated me before.

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