Pre-Existing Conditions Still Being Avoided?

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September 18th, 2014

Pre-Existing ConditionsFor sick patients with costly pre-existing conditions, the ACA was seen as an opportunity to be viewed equally in terms of insuring their health. While extending coverage to those who would have beforehand been denied was a key selling point of the new health law, insurers are still finding ways around being unable to reject customers with expensive medical conditions.

Many have opted to design and offer marketplace plans that discourage sick and more costly individuals from enrolling. Insurers are now offering plans that are designed to purposely exclude cancer centers and special high-cost facilities and require patients to make larger initial payments on HIV medications, or have delayed product participation in public exchanges to avoid the rush of sicker patients.

How Insurers Avoid Patients with Pre-Existing Conditions

More insurers are beginning to use the following techniques to discourage the sick from enrolling:

Forming Narrow Networks

Sicker patients often require more expensive doctors or hospitals for expensive medical conditions. Insurers can eliminate the likelihood of an already sick patient enrolling in their plan by building narrow provider networks that steer patients elsewhere due to expensive out-of-network rates. Many narrow networks contract only 30% of the regions providers. Additionally, narrow networks provide insurers with leverage when bargaining costs with providers – who would prefer to continue to be included in the network and receive the insurer’s business.

Many have called for regulation over these network structures, and a CMS spokesperson has already indicated there are plans in place to increase the review of these networks for 2015 and determine if new requirements must be put in place.

Prescription Sticker Shock

While the health law was put in place to cap annual out-of-pocket limits, higher cost-sharing requirements are still being used to steer sick patients that need high-price prescription medication elsewhere. Specifically with regards to HIV drugs and multiple sclerosis medication, many insurers now require patients to pay an initial 30% more of the bill for drugs that can cost thousands of dollars each month. The AIDs institute recently filed a complaint to the HHS against four Florida insurance companies over the rise in cost-sharing for HIV medication.

Delayed Market Entry

When the public insurance exchanges opened, many sick patients rushed the marketplace as they were guaranteed coverage for the first time. In response, some insurers have opted to delay their entry into the marketplace to avoid these higher-cost individuals and monitor closely both utilization and consumer trends.

While these techniques have been voiced as discrimination against the sick, insurers have come to their defence stating that changes to coverages are in response to prudent business practice. Furthermore, insurers have been keen to point out that the health law has provisions in place to prevent selling such ‘discriminatory’ plans.

Regardless of who may be to blame, for patients with costly pre-existing conditions, it remains a difficult task to find coverage that is comprehensive enough to meet their needs at an affordable price. PayerFusion offers many of its covered members provider steerage assistance and can help patients find and negotiate cheaper alternatives to the prices they're paying for treatment of their pre-existing conditions.


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