CMS Launches Investigation Into Potentially Discriminatory Plans

The Obama administration has announced that it will investigate prescription drug plans and other health benefits offered by insurers to determine whether companies are discriminating against people with chronic conditions such as AIDS, mental illness and diabetes, the New York Times reports.

Background

Insurers are prohibited under the Affordable Care Act from charging certain consumers higher premiums because of medical conditions.

However, patient advocates have alleged that insurers are limiting benefits for such individuals in other ways, the Times reports.

Details of Investigation

The administration said it is launching the investigation because it became aware of "discriminatory benefit designs" that discourage people from enrolling in certain plans because of medical condition or age.

In a letter to insurers, CMS warned that a plan could be discriminatory if its list of approved prescriptions excluded all treatments for a certain condition or if it restricts access to those drugs by requiring considerable copayments or prior authorization.  Specifically, CMS wrote that if an insurer "places most or all drugs that treat a specific condition on the highest-cost tiers, the plan design effectively discriminates against, or discourages enrollment by, individuals who have those chronic conditions."

Further, CMS said it would challenge benefits restrictions if they are not rooted in "clinically indicated, reasonable medical management practices." For example, the agency said plans' "age limits are discriminatory when applied to services that have been found clinically effective at all ages."

For the investigation, CMS said it would inspect insurers selling plans through the federal exchange by determining the plans' "estimated out-of-pocket costs associated with standard treatment protocols for specific medical conditions using nationally recognized clinical guidelines." CMS said those conditions likely would include:

• Bipolar disorder;
• Diabetes;
• HIV/AIDS;
• Rheumatoid arthritis; and
• Schizophrenia (Pear, New York Times, 12/22/14).

Consumer Group Sues Aetna Over Alleged Discrimination

In related news, the Consumer Watchdog group has filed a lawsuit against Aetna, alleging that its plan to require patients with HIV to obtain medications only through its own mail-order pharmacy is discriminatory, the Times reports.

Aetna's policy is scheduled to take effect on Jan. 1, 2015. According to the lawsuit, it would apply only to consumers who purchase individual health plans, requiring them to obtain the drugs through Aetna Specialty Pharmacy. In addition, the policy would not permit patients to obtain more than 30-day supplies of the drugs and would not allow early refills.

Aetna states that it permits beneficiaries to opt out of the mail-order requirements, but one of the plaintiffs in the lawsuit alleges that his requests to do so were repeatedly denied, according to the Times (Thomas, New York Times, 12/22/14).

Consumer Watchdog filed the suit in federal court in San Diego (Watson, AP/San Francisco Chronicle, 12/23/14).

The group argues that the policy violates provisions under the ACA that prohibit insurers from discriminating against individuals based on medical conditions (New York Times, 12/22/14).