The Obama administration says it will investigate benefit plan designs for discrimination against individuals, including suspect practices that discourage people with costly medical conditions from enrolling in a plan.
In a letter to issuers that plan to offer qualified health plans in the federally-facilitated marketplace, the Centers for Medicare & Medicaid Services cautions issuers to avoid discouraging enrollment of individuals with chronic health needs.
For purposes of QHP certification, CMS says it will collect from insurers an attestation that issuers QHPs will not discriminate against individuals on the basis of health status, race, color, national origin, disability, age, sex, gender identity or sexual orientation.
In addition to complying with these non-discrimination standards, QHPs must not employ market practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs.
The agency adds it will continue to assess compliance with non-discriminatory practices through issuer monitoring and compliance reviews, including analysis of appeals and complaints.
CMS will investigate health plan designs for fair practices on co-payments, coinsurance and cost-sharing with respect to specific benefits. The agency is also considering a review of each QHP to identify outliers based upon estimated out-of-pocket costs associated with standard treatment protocols for specific medical conditions using nationally-recognized clinical guidelines.
The conditions under consideration for CMS investigation include: bipolar disorder, diabetes, HIV, rheumatoid arthritis, and schizophrenia.
For example, the administration says, a discriminatory practice may include an issuer refusing to cover a single-tablet drug regimen or extended-release product that is customarily prescribed and is just as effective as a multi-tablet regimen.
Absent an appropriate reason for such refusal, such a plan design effectively discriminates against, or discourages enrollment by, individuals who would benefit from such innovative therapeutic options, CMS says in the letter.
In another example, CMS says, if an issuer places most or all drugs that treat a specific condition on the highest cost tiers, that plan design effectively discriminates against, or discourages enrollment by, individuals who have those chronic conditions.
CMS says it will notify an issuer when it sees an indication of a reduction in the generosity of a benefit in some manner that could be viewed as discriminatory and insurers may be asked to submit justification with supporting document to CMS explaining how the plan design is not discriminatory.
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