Looking Beyond Premiums & Secretary Burwell Response
Earlier this summer, the I AM (Still) ESSENTIAL coalition sent a letter to HHS Secretary Burwell alerting her of various access-to-care issues patients have experienced during their first year of enrollment in qualified health plans. Signed by 333 patient organizations, the letter outlined key areas of concern including limited benefits (particularly related to prescription medications and provider networks), high cost-sharing, and lack of transparency and uniformity. In her response received last week, the Secretary addresses some of the issues that we raised.
As we look forward to year two, we are eager to review the 2015 qualified health plans when the open enrollment period begins on November 15th. The I AM (Still) ESSENTIAL coalition and the patients we represent, especially those living with chronic health conditions, are anxiously awaiting plan details. We will be examining plans closely this year, beyond simply focusing on premiums, to ensure that the 2015 plans are better for patients than those in 2014.
Below is a list of questions that we will be asking as we review the plans. Finding answers to these questions will be the best way to determine if the concerns that we detailed in our letter to Secretary Burwell have been addressed.
1. Have prescription drug formularies narrowed or expanded?
- Plans must include the greater of at least one drug per class or the number of drugs in each class as contained the state's benchmark. In 2014, some plans exceeded the benchmark requirements while others simply met the minimum drug coverage requirement. Some plans did not include combination therapies.
2. Have medications approved over the past two years been added to the formularies?
- For a list of newly approved drugs go to: http://www.centerwatch.com/
drug-information/fda-approved- drugs/
3. Have deductibles decreased or increased, including separate prescription drug deductibles?
- Some plan deductibles were as high as the maximum patient out of pocket costs, which means that the plan would only begin to pay for costs after the beneficiary has spent $6,300 for an individual.
- According to a RWJF study, exchange plans had an average combined medical and prescription deductible of $2,763 in 2014. Among the plans with a separate prescription drug deductible, the average was $933.
4. Are plans utilizing co-insurance instead of co-pays, and if so, at what percentage?
- An Avalere study found that 59 percent of Silver plans on exchanges across the nation use coinsurance for consumer cost-sharing on the specialty tier.
- The analysis also found that 23 percent of plans have coinsurance rates of 30 percent or more on the highest formulary tier.
5. Are plans utilizing discriminatory practices by placing certain classes of drugs all on high tiers and does this include generics?
- The ACA prohibits issuers from using "benefit designs that have the effect of discouraging the enrollment in such plan by individuals with significant health needs". In 2014, some plans placed all drugs, including generics, in a certain class on the highest cost-sharing tier.
6. Are patients able to access complete drug formularies and provider networks easily?
- In 2014, users of plan websites found it difficult to locate complete lists of drugs that the plan covered or a directory of medical providers in each plan's network.
- For 2015, CMS is requiring plans to list one single web address with complete plan formularies and provider directories without a consumer having to log on.
7. Are patient cost-sharing and utilization management policies clearly defined? Is utilization management being more widely used?
- In 2014, consumers found it difficult to determine how much they had to pay for their medications. CMS will be requiring plans in 2015 to include tiering information.
- The use of co-insurance makes it even more difficult for patients to determine their out of pocket costs. An analysis by Avalere of exchange plans found that plans on the exchange were more likely to use utilization management techniques than employer plans.
- CMS has said they will be reviewing plans "that are outliers based on an unusually large number of drugs subject to prior authorization and/or step therapy requirements in a particular category and class."
Angela Ostrom
Chief Operating Officer
Epilepsy Foundation
Carl Schmid
Deputy Executive Director
The AIDS Institute
Andrew Sperling
Director of Federal Legislative Advocacy
National Alliance on Mental Illness
