Coventry Health Care, Inc., which offers Qualified Health Plans (QHPs) in Florida under the name CoventryOne, is wholly owned by Aetna, which reported over $47 billion in revenue for 2013.
Cigna is headquartered in Bloomfield, Connecticut, reporting $32 billion in revenue for 2013.
Humana is headquartered in Louisville, Kentucky, reporting over $41 billion in revenue for 2013.
Preferred Medical is headquartered in Coral Gables, Florida. Its 2013 annual report is not available.
This complaint is filed pursuant to Section 1557 of the Patient Protection and Affordable Care Act (ACA), codified at 42 U.S.C. § 18116. Section 1557 prohibits federal health programs, activities, and contracts of insurance sold through the health insurance Marketplaces from discriminating against individuals living with disabilities, including HIV and AIDS. The HHS Office of Civil Rights (OCR) has primary responsibility for ensuring compliance with Section 1557 through investigations and enforcement action. Although the HHS OCR has primary oversight over Section 1557, the Department of Justice (DOJ) has coordinating responsibility pursuant to Executive Order 12250.
Under the ACA, health insurers may no longer discriminate on the basis of disability. Section 1557 and other ACA provisions prohibit discriminatory health insurance practices, including plan benefit designs which discourage enrollment of persons with significant health needs, including people living with HIV and AIDS.
The AIDS Institute conducted an analysis (available here
; hard copy attached) of the prescription drug formularies and cost structure for all silver-level Qualified Health Plans (QHPs) operating in Florida. The analysis found that, of the 36 plans reviewed, the QHPs offered by CoventryOne, Cigna, Humana, and Preferred Medical charge inordinately high co-payments and co-insurance for medications used in the treatment of HIV and AIDS. Other plans available through the Marketplace offer HIV/AIDS medications in a range of tiers and cost sharing structures.
- CoventryOne places all HIV drugs on Tier 5, including generics (with a 40% co-insurance after a $1,000 Rx deductible) and most require prior authorization.
- Cigna places all HIV drugs on Tier 5, including generics (in some plans with a 40% co-insurance after deductible ranging from $0 to $2,750).
- Humana places all HIV drugs on Tier 5, including generics (with a 50% co-insurance after a $1,500 Rx deductible).
- Preferred Medical places all HIV drugs on a Specialty Tier, including generics, and requires 40% co-insurance. It is unclear which require prior authorization.
The QHP drug benefits offered by CoventryOne, Cigna, Humana, and Preferred Medical impose overly restrictive utilization management which unduly limits access to commonly used HIV/AIDS medications. Moreover, by placing all HIV/AIDS medications, including generics, on the highest cost-sharing tier, CoventryOne, Cigna, Humana, and Preferred Medical discourage people living with HIV and AIDS from enrolling in those health plans – a practice which unlawfully discriminates on the basis of disability.