Those in Minnesota’s high-risk health exchange pool look to unclear future [Pioneer Press, St. Paul, Minn.]

Aug. 24--Annie Elmer is an optimist.

When she was diagnosed with HIV in 1990, it was tantamount to a death sentence.

But the outlook soon changed with new medications, and now -- more than two decades later -- Elmer works as a personal trainer, trying to help others stay healthy.

It might not be surprising, then, that as Elmer looks forward to changes in the nation's health system next year, she's not dwelling on the chance for problems.

With the federal health care overhaul, Elmer will be expected to switch into the new marketplace for health insurance policies. Right now, it's unclear exactly what kind of coverage she'll find for the doctors and medications that have been key to her survival.

"I think it's going to be good," said

Elmer, 55. "That being said, I haven't really seen what policies are going to be available to choose from."

A hardy dose of optimism is coming in handy this summer for about 26,000 people who are like Elmer in having received health insurance in the past through the state's high-risk pool program.

As they look to a future that eventually involves shopping for coverage on the private market, patients in high-risk pools don't yet have access to information about which doctors and medications will be covered by the new health insurance options available next year.

It's also unclear what will happen to people's out-of-pocket costs for coverage, which will depend on 2014 premiums -- which haven't been released -- plus an individual's eligibility for tax credits.

Traditionally, people in high-risk pools have had to pay more for their health insurance.

"We're in a wait-and-see mode, to see what these plans will actually look like and what they will cost," said Matt Toburen with the Minnesota AIDS Project.

REPLACING A SAFETY NET

In Minnesota, the high-risk pool is called Minnesota Comprehensive Health Association, or MCHA, and it has served for more than 30 years as a safety-net insurer for people with costly, chronic health conditions. The nonprofit group was established by the Legislature in 1976 and is regulated by the state's Commerce Department.

Its ranks include about 400 people who have HIV/AIDS and qualify for a federal program that helps cover premium costs. Another 200 or so have multiple sclerosis; about 700 people get coverage through the program for rare diseases; and about 40 are on waiting lists for an organ transplant.

The common denominator: People in MCHA couldn't get coverage on the private health insurance market because they have a pre-existing health condition.

The need for high-risk pools is going away because the federal health law prohibits insurance companies starting next year from denying people

coverage based on pre-existing conditions. Most state high-risk pools are being shut down as a result.

In Wisconsin, the state's Health Insurance Risk Sharing Program is scheduled to close by year's end, meaning nearly 25,000 people will need to find new insurance.

Minnesota officials have signaled their intent to maintain the state's high-risk pool through the end of next year for people currently covered by it.

By the end of August, the Minnesota Department of Commerce expects to release final decisions about the program's future. A draft proposal called for closing MCHA to new members by the end of the year and encouraging current members to consider new options including MNsure, which is the state's new government-run health

insurance exchange.

"The law provides an opportunity for people with high-cost, chronic conditions to buy health insurance like anybody else," said Lynn Blewett, a professor of health policy and management at the University of Minnesota.

"You're going to have choices among products, so that's going to be good," Blewett said. "But they're likely going to be managed products, so there will be more limited networks -- that's how we contain costs."

ACCESS TO NETWORKS

The term "network" is how insurance companies refer to the group of doctors and hospitals that are available to patients in a given health plan. MCHA's network has been relatively broad, and enrollees have appreciated it.

In a survey released earlier this year, 40 percent of MCHA members said their ability to go to the Mayo Clinic in Rochester, Minn., was an important feature of their coverage. Once members start shopping for commercial policies, they likely will find some plans don't include the Mayo Clinic, said Kirby Erickson, the executive director of MCHA.

Network concerns aren't unique to Mayo Clinic patients. This summer, the Commerce Department has been taking public comments, and one patient with a rare neurological condition wrote that no more than 15 doctors in the world treat the ailment.

"I am fortunate beyond measure that one (doctor) is local," the patient wrote in an email. "When that (doctor) retires, which is a possibility, my best option is France. ... I need the continued level of care I have now, and I need it to extend to foreign countries."

Another patient praised MCHA for its "excellent coverage" for ulcerative colitis and wondered whether coverage under the federal health law would permit continued treatment with the same doctors. The patient's concern about network blended over into another key area for many in the high-risk pool: medication coverage.

"The medication I take ... every six weeks, by infusion, is expensive," the patient wrote in comments submitted to Commerce. "The cost, approximately $5,000 per treatment, has been covered under the MCHA plan. I know that many plans don't cover expensive medication, even if it is required."

DRUG COVERAGE

Commercial health plans often have differences in how they structure "formularies," meaning the lists of drugs that are covered with varying degrees of copayments from patients.

Adjusting to a new formulary can be difficult for patients who have spent years finding drugs that help control a condition without extensive side effects. That was true for Elmer, the HIV patient who relies on a strict regimen of four anti-AIDS medications.

"People are very sensitive, once they've found drugs that help them -- they don't want to mess with that," said Erickson, the executive director of MCHA.

Health plan formularies often place medications on different tiers, with many generic drugs being placed on a tier with low copayments. Many patients with high-cost conditions, however, don't have a generic option.

In the past 15 years, for example, multiple sclerosis patients have benefited from the development of 10 new medications that can significantly reduce disease activity and progression, said Daniel Johnson, vice president for public policy at the National Multiple Sclerosis Society, Upper Midwest Chapter.

Insurance coverage through MCHA has provided some level of coverage to all 10 of the drugs, Johnson said. But the "benchmark plan" that sets minimum standards for what will be covered in Minnesota health plans under the federal law includes lesser coverage, he said.

To the extent that there are marketplace gaps for people in MCHA, the Commerce Department's report due this month should help identify solutions, said April Todd-Malmlov, the executive director of MNsure.

Todd-Malmlov pointed out that the benchmark plan sets a floor for the sort of drug coverage that health plans must cover -- not a ceiling. So, it's possible that plans sold through the health exchange will include access to MS drugs, for example, that's comparable to MCHA.

On the topic of networks, Todd-Malmlov said it's likely that health plans sold through the exchange will provide different levels of access to doctors and hospitals. But all plans will need to meet standards that govern the adequacy of networks.

In addition, MNsure is meant to be a marketplace -- meaning an exchange where companies will sell policies in many different shapes and sizes. So, the state will direct MCHA consumers to health insurance agents and brokers who can help people analyze which policies are the best fit, Todd-Malmlov said.

Agents and brokers have experience with MCHA patients and can help them analyze options on the state's health exchange as well as those being sold "outside" the new government marketplace, said Dave Racer, spokesman for the Agents Coalition for Health Reform, a broker group.

"Agents today are pulling out all their records and starting to contact MCHA people that they helped enroll originally," said Racer, whose group launched a website called myMCHAagent.com.

SEEKING DETAILS

For now, there just aren't answers to questions about doctor networks and drug formularies. Information about the cost of MNsure policies is scheduled to become available on Sept. 6, but patients at that point won't have access through the government-run exchange to detailed information about doctors and medications.

The information also won't be available on the MNsure website when it opens for business Oct. 1. At some point between October and March, MNsure hopes to launch a search function on its website so consumers can shop for health plans on the basis of whether a particular hospital or clinic (although not a particular physician) is in a health plan's network.

In Wisconsin, where the health exchange will be operated by the federal government, a new consumer website will have similar limitations, said Amie Goldman, the chief executive officer of the state's high-risk pool.

Since current MCHA members can continue their coverage next year, Minnesota has a backstop for handling transition problems. There's no such grace period in Wisconsin, where the state's high-risk pool is particularly focused on three groups: people on transplant waiting lists; people who take specialty medications; and people with lengthy hospitalizations in December that extend into the new year.

For transplant patients and people on specialty drugs, maintaining access to therapy or a spot in line for an organ involves a pre-approval process with a health insurer, Goldman said. So, officials want to help Wisconsin high-risk pool members make sure a shift in coverage at year's end doesn't block their access to medicine or an organ in January.

"If you're in the hospital in December, and you were waiting to sign up for new coverage, it's something that could easily get lost track of," Goldman said. "We want to make sure that if your hospital stay crosses over into January that you have other coverage that will pick up on Jan. 1."

Transitions always bring the possibility of problems. But the broader point for people in high-risk pools is that the change should be a good thing, said Blewett of the U, because their care costs will be spread across a broader population.

That means there's a chance that some with costly health problems could find coverage more affordable, she said. There will also be no limit to coverage; Minnesota's current MCHA pool, for example, caps lifetime benefits at $5 million, Blewett said

"They'll have a choice of plans. They'll have a baseline of coverage," she said. "It treats them like everybody else."

Christopher Snowbeck can be reached at 651-228-5479. Follow him at twitter.com/chrissnowbeck.

___

(c)2013 the Pioneer Press (St. Paul, Minn.)

Visit the Pioneer Press (St. Paul, Minn.) at www.twincities.com

Distributed by MCT Information Services