Advotcate Says Exchange Copays Hurt Low Income Vermonters with Chronic Conditions

September 21, 2014

By Morgan True

Many people with chronic health conditions who are covered through Vermont’s exchange are finding it difficult to pay out-of-pocket costs for care, a consumer advocate says.

Trinka Kerr, who leads Legal Aid’s Office of Health Care Advocate, told lawmakers this week that the problem is the way health plans offered through Vermont Health Connect are designed.

People with chronic conditions that require frequent treatment, such as diabetes or heart disease, and who formerly qualified for a subsidized state program, are now liable for copays under the exchange.

The Catamount Health Plan, which was dissolved when the state adopted a health care exchange system, eliminated copays for patients who qualified for Chronic Care Management programs.

Commercial health plans sold on the exchange don’t waive copays for those treatments, and many people are having difficulty keeping up with the payments, Kerr said.

It was a serious problem for people who needed daily substance abuse treatment, such as methadone or suboxone, Kerr said, but that issue was alleviated when Blue Cross Blue Shield of Vermont moved to a flat monthly copayment.

However, the copays remain a problem for people with chronic illnesses.

Those who were covered by VHAP, another state subsidized health plan that expired with the implementation of the Affordable Care Act, had no copays for prescription drugs.

Under the new eligibility rules for Medicaid, those people now have copays for prescriptions. Though the copays are typically $1 to $3 each, Kerr said people with very low incomes are having trouble covering them.

The Department of Vermont Health Access, which still oversees Medicaid despite responsibility for the exchange being moved elsewhere within the Agency of Human Services, provided some relief by reminding pharmacies that they can’t refuse to fill a prescription for lack of a copay.

That solution “kicks the can down the road,” Kerr said, because pharmacies can tell customers that they won’t fill a prescription in the future unless the person pays their bill. That could leave poor Vermonters skipping from pharmacy to pharmacy to avoid copays.

Kerr said her office hasn’t heard complaints from consumers about “high deductibles” on the exchange. Hospitals recently said the plans could drive up uncollectible accounts and charity or discounted care.

But Tom Huebner, CEO of Rutland Regional Medical Center, who raised the issue in his budget presentation to state regulators, has since clarified that his hospital was referring to the total out-of-pocket costs for exchange plans.

Kerr said that makes more sense to her, and she has heard concerns from consumers about the out-of-pocket costs.

“We have talked to some consumers who did not understand the cost sharing of their new plans, and were upset about the costs they incurred when they a started to use their insurance,” Kerr wrote in a statement provided to lawmakers.

In many cases, it’s an issue of “health care literacy,” Kerr said, adding that people who bought low premium health plans may not have realized that they were signing up for higher out-of-pocket costs.

Kerr said the plans that will be sold during the upcoming open enrollment period starting in November have largely the same design, and she expects this will continue to be an issue.