Some Missourians with HIV will lose health insurance coverage in 2018

Dec. 15--Some HIV-positive patients in nearly half of the counties in Missouri will lose health insurance coverage in 2018, state officials said.

About 95 HIV patients in Missouri will no longer have access to a comprehensive health insurance plan due to high costs, according to the Department of Health and Senior Services.

The state of Missouri has started notifying some HIV-positive patients in 51 Missouri counties about the coverage changes. The state helps direct federal funds from the Ryan White program to help those with HIV afford and access health care.

"Available insurance plans in (51) counties do not meet ... mandated cost effectiveness criteria," said Sara O'Connor, spokeswoman for the Department of Health and Senior Services.

Although these individuals will no longer have access to comprehensive health coverage, effective Jan. 1, the state says they will still have access to the medications they need. The state will move from buying insurance to buying the drugs used to treat the disease.

In fact, that's how the program was originally designed to work. States typically used the money to buy the medications and provided access to specialists related to the treatment of the disease.

After the Affordable Care Act went into effect, however, some found it was more cost-effective to use the federal funds to pay for health insurance instead of just drugs. By purchasing coverage, patients gained access to more comprehensive health care services such as primary care physicians, hospital stays and emergency room visits.

About 500,000 low-income individuals throughout the country rely on the Ryan White funding. It's the largest source of federal grant money used to help patients with HIV, according to the Kaiser Family Foundation.

Missouri is said to be the only state that has decided it is too costly to provide the funds for coverage in certain counties, according to Martin Kramer, spokesman for Health Resources and Services Administration, the department that oversees the Ryan White program.

In 2017, more than 2,300 Missourians relied on the program for coverage, according to O'Connor, spokeswoman for Missouri's Department of Health and Senior Services.

The loss of coverage will be felt more in the rural areas of the state; those in the St. Louis and Kansas City areas will still have coverage.

"It has created a significant disparity in access to care based on location," said Cale Mitchell, executive director of Spectrum Health Care, which serves as case managers for those with HIV.

Problems with competition

One of the problems is the lack of competition among insurance carriers in the 51 counties affected. Only one insurance carrier sells plans there: Anthem Blue Cross Blue Shield.

According to a Post-Dispatch review of Anthem's drug plan, all of the most commonly used HIV medications that are covered by Anthem are on the highest tier of drug coverage. Many health plans group drugs into tiers. Typically, the higher the tier, the more costly the drug for the patient, or in this case the Ryan White program, which picks up many out-of-pocket expenses.

On tier four, co-insurance is triggered, which means a patient picks up a percentage of the total cost of the drug instead of paying a flat fee such as a copay.

Anthem does not dispute that its HIV drugs are on the highest tier.

"One of the biggest challenges in healthcare is the rising cost of specialty drugs. Next year, Anthem will pay more than half of all money spent to cover members' prescription drugs on high cost specialty drugs. As a result, many specialty drugs, like HIV drugs, are on higher-tiers and require co-insurance," Anthem said in a statement to the Post-Dispatch.

Federal health regulators warned insurers in 2015 that placing most or all of the drugs needed to treat a condition on the highest-cost tier could be deemed discriminatory.

Other carriers in the state place HIV drugs on lower tiers that don't trigger co-insurance.

Cigna and Centene's insurance plans place many of the HIV drugs on lower tiers in which a nominal copay is required, according to a Post-Dispatch review of the benefits.

For example, Cigna places many of its HIV drugs on tier three. (Cigna has five tiers). On tier three, the drugs require either a $50 copayment or a $150 copayment if the drug is delivered to the patient's home.

Patients who rely on the Ryan White funding for coverage and live in the St. Louis area will have the choice of a Cigna or Centene plan for 2018.

To be eligible for the comprehensive health insurance coverage in Missouri, the HIV patient must have an annual income at or below 300 percent of the federal poverty level. For an individual, that would mean an annual income no greater than $36,180.

Another issue for those who will no longer get health coverage is the possible fine they could face for not having health insurance.

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