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Affordable Care Act: State Rules Can Boost Costs


Virginia’s pricing “is a barrier for people getting coverage,” Joe Nadglowski, president and CEO of the Florida-based advocacy group Obesity Action Coalition.  “Some of the decisions that insurers make around bariatric surgery seem not to be based on economics or health, but are often more based on stigma and bias.”

One mid-level policy from insurer Optima that covers the treatment, for example, is priced at $1,858 a month for a 27-year-old, but the same plan from the same insurer is $285 without the rider.  Similar plans by other insurers, including Aetna, Coventry One and Innovation Health, range from $1,100 a month to $1,500, well above what the insurers charge for plans without the rider.

A spokesman for Blue Cross Blue Shield of Georgia said that insurer is not offering riders that cover the surgery in its policies sold in the new marketplaces.

Under the health law, benefit packages must include 10 broad categories of care, including hospital coverage, maternity care, prescription drugs and mental health services. But states were given some leeway in choosing what else to include in that list. Along with Virginia, 27 other states chose benchmark policies that do not cover the surgical treatment for obesity, according to an analysis by the obesity coalition.

Maryland chose a benchmark plan that does require coverage, reflecting its longstanding law.  A Maryland Health Care Commission report from last year estimates the state’s mandate to cover treatment for severe obesity added about 0.4 percent to the cost of an individual health policy, far below the 600 percent differential seen in some of the plans with riders in Virginia.

Maryland Plans ‘More Affordable’


In states like Maryland where the cost of surgical treatment for obesity is included in all plans, the premiums are “more affordable than the Virginia plans with the add-on bariatric coverage, which drives up the price for those specific plans,” said Aetna spokeswoman Cynthia Michener.  

Some question whether Virginia insurers may be “adhering to the letter of the state law but not the spirit of the federal law,” said Deborah Chollet, a senior fellow at Mathematica Policy Research, a nonpartisan research firm in Washington.

That’s because the federal law says insurers cannot reject patients with medical conditions, nor charge them more, starting Jan. 1. Severe obesity is considered a disease, according to the American Medical Association.

“The health law says you cannot discriminate based on health conditions,” said John Morton, chief of bariatric and minimally invasive surgery at the Stanford University School of Medicine and president-elect of American Society for Metabolic and Bariatric Surgery. “Here they are adding a premium to a disease. It’s coverage in name only. It’s disgraceful. “

The legal arguments are not a slam dunk.

Fri, Oct 11 2013

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