The Center for Health Law and Policy Innovation (CHLPI) has developed templates for people infected with HIV to file complaints about Health Insurance Discrimination. They are developing additional templates for people with Hepatitis C or with a generic medical condition.

Health Insurance Discrimination refers to those policies designed to drive away people with expensive conditions. For example, plans may place needed medications on the most expensive tier, require onerous pre-authorizations, or fail to provide an appeals process. Besides discriminating against the affected individuals, it drives high cost patients to competitors. It not only discriminates, but it also subverts fair competition.

HIVHealthReform.org and the CHLPI presented a webinar “A New Tool to Fight Health Insurance Discrimination.” Carmel Shachar, from CHLPI, led this webinar. This webinar introduced two templates for filing complaints with insurance regulators: a longer one for providers and advocates, and a shorter one for consumers. Consumers can use either.

Complaints to insurance companies frequently fail to resolve issues. Some just give a perfunctory review re-affirming the denial, and others just fail to respond. When one level does not work, Shachar recommends that people move up to the next higher level. The next level consists of filing a complaint with insurance regulators at the state level. These CHLPI templates should facilitate that process.

Under the Affordable Care Act (ACA), state insurance regulators must enforce its anti-discrimination provisions. Most states have failed to align their regulations with the new insurance landscape. If a state has sympathetic or neutral regulators, complaints on file can provide them with political cover and counterbalance lobbyists. If a state has hostile regulators, complaints on file can become evidence in subsequent litigation and facilitate moving up to the federal level. This process draws attention to the issue, and avoids the adversarial relationship of litigation, with its slow pace and high costs.

Shachar identified three types of complaints:

1. Changing the terms of coverage after its purchase
2. Refusing to cover standard care for HIV
3. Unreasonably high costs for standard medications or treatment

The template consists of the following parts:

1. The complaint
2. Relevant sections of the ACA
3. The standard of care for HIV infection
4. Federal anti-discrimination law and the responsibility of state insurance regulators to enforce it.

Some insurance regulators may lack familiarity with the standards for HIV care. One complaint can include multiple problems. Shachar stressed that people should feel free to contact her if they had any questions.

CHLPI based these templates on Marketplace plans and HIV infection. Some people will have complaints about other types of plans or other conditions. People with such complaints should contact Shachar, rather than modifying the template themselves.

The CHLPI will update the template when regulations or standards of care change. People should always download the templates to ensure they are current, rather than storing them on their computer.

Shachar recommends sending copies of the complaint to the insurance company, to the CHPLI, and to sympathetic state politicians. They also suggest sending both hard and electronic copies to the state regulator, as well as a follow-up meeting.

One of the unintended consequences of the ACA involves increased public education about resolving complaints about plans and getting results. This may be one of its many significant reforms.

To download the templates or to view this webinar, visit: http://bit.ly/1gdoSkd

For questions about the template and its use, contact Carmel Shachar 617-390-2588 or This email address is being protected from spambots. You need JavaScript enabled to view it..

For more information, visit Center for Health Law and Policy Chlpi.org or HIV Health Reform http://www.hivhealthreform.org.

To access the Florida Office of Insurance Regulation, please visit Floir.com.


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