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Insurers limiting drug coverage to keep people with costly conditions from enrolling

Written by Diane Archer

When was the last time you heard of a health insurer advertising its first class cancer care, its impressive slew of specialists or its low costs to people with complex conditions? In fact, you’ve likely only heard them promoting their health and wellness programs, encouraging healthy people to enroll and discouraging people with complex conditions from enrolling. Kaiser Health News reports on the latest scandal: insurers limiting drug coverage to keep people with HIV from signing up with them.

As we all know, first and foremost, commercial health insurers are in the business of making money and delivering returns to their shareholders. Unfortunately, this can translate into health insurers discriminating against people with costly and complex conditions to keep their costs down and profits up. That’s why most people with Medicare opt for traditional Medicare over a commercial health insurer that offers Medicare benefits.

To be clear, it is illegal for health insurers to turn people away because they are in poor health or to design their benefits in ways that discriminate against people with serious health conditions. Yet, HHS has never defined discrimination, so discrimination can be hard to prove.

As a result, some insurers innovate with their marketing, their benefit designs, and their cost structures to attract as healthy members as possible and discourage others from enrolling. They market to people who can travel independently. They keep their networks narrow, without the array of specialists people who are sick may need. They make out-of-pocket costs particularly high for people needing a lot of care. And, they limit their drug coverage.

Harvard Law School’s Center on Health Law and Policy Innovation is now taking to task seven insurers in eight states for their failure to make necessary HIV drugs affordable or available for patients. It has filed complaints with the HHS Office for Civil Rights against Humana, Cigna, Independence Blue Cross, Anthem Blue Cross Blue Shield and UPMC health plan, Community Health Choice and Highmark. We can only hope that the Trump Administration will acknowledge this discrimination and address it.

Here’s more from Just Care:


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