August 26, 2010

Jay Angoff, JD, Director

Office of Consumer Information and Insurance Oversight

Department of Health and Human Services  

Attention: OCIIO–9994–IFC

Room 445–G

Hubert H. Humphrey Building

200 Independence Avenue, S.W.

Washington, DC  20201

Subject:   HIVMA Comments on Interim Final Regulations for Implementation of

Provisions of the Patient Protection and Affordable Care Act Regarding Pre‐

Existing Condition Exclusions, Lifetime and Annual Limits, Rescissions, and

Patient Protection (Ref# OCIIO–9994–IFC)

Dear Mr. Anghoff:

The HIV Medicine Association (HIVMA) appreciates the opportunity to comment on

the above‐referenced proposed rule.  HIVMA represents more than 3,800 HIV

clinicians and researchers working on the frontlines of the HIV epidemic in

communities across the country.

We strongly supported the “Patients’ Bill of Rights” provisions of the Patient

Protection and Affordable Care Act (ACA), because we have seen firsthand the need

for much stronger consumer protections in the private insurance market to prevent

discrimination against our patients with HIV disease.  We are hopeful that

implementation of these important regulations will expand access to affordable, high

quality health care coverage through the private health insurance market for

individuals with HIV.  We urge you to grant serious consideration to our

recommendations on these issues in formulating the final rule.     

Our comments focus in particular on two areas of concern:   

• The importance of ensuring access to HIV clinicians by requiring plans to

contract with HIV clinicians and allowing patients to designate an HIV clinician

as their primary care provider; and,  

• The continued permissibility of categorical exclusions of coverage for specific

conditions or diseases.

1) Inclusion of HIV Clinicians in Provider Networks

It is essential that patients living with HIV disease have reliable and streamlined access

to an experienced HIV provider.   There is ample evidence in the research literature

that care delivered by experienced HIV providers regardless of specialty training

translates into improved clinical outcomes and the more cost effective delivery of  
HIV Medicine Association

Comments on Interim Regulations [OCIIO‐9994‐IFC]

August 26, 2010

Page 2

  

  

care.i

   In the past, some insurers have excluded HIV clinicians from their provider networks to discourage

enrollment of individuals with HIV disease.  

We urge you to eliminate these practices by requiring plans to contract with HIV medical providers.

The role of the HIV clinician has evolved with the availability of effective HIV treatment.  Persons with HIV

infection who have access to care are now surviving to near expected life spans of the general population and

developing common conditions associated with aging.  With these changes, the majority of HIV physicians

have adapted to meet the needs of their patients by managing their primary care and HIV treatment.  

We strongly urge you to ensure patients with HIV disease maintain appropriate contact with their HIV

providers by requiring plans to do one of the following to ensure timely access to HIV clinicians:   

• Allow HIV clinicians regardless of specialty training to serve as designated primary care providers;

• Create a standing referral to an HIV provider without prior approval or authorization; or,

• Allow direct access to an HIV provider without a referral.  

States such as California have adopted standing referral requirements for HIV patients enrolled in managed

care plansii (Arizona and New Jersey have adopted similar policies).  

2) Categorical exclusions of coverage for specific conditions or diseases

We applaud private insurance market reforms under the ACA that when fully implemented will instill greater

fairness and allow more consumers to access adequate, affordable coverage through the private health

insurance market.  We understand that many of the most critical consumer protections for adults will be

phased in over time or do not take effect until 2014 – including essential benefit requirements, guaranteed

issue and prohibition of discrimination against individual participants and beneficiaries based on health

status.  The current proposed rule underscores the importance of those essential protections, in that it

explicitly does not prevent a plan or issuer from excluding coverage for all benefits for a condition, such as

HIV disease.  

We urge you to closely monitor the practices of private insurers in this regard.

We look forward to future issuance of regulations to implement additional consumer protections that will be

critical to eliminating insurer discrimination against individuals with serious, chronic conditions, such as HIV

disease in 2014.    

Thank you for your consideration of our views, and please contact us if we can provide further information.   

We can be reached through our Executive Director, Andrea Weddle (aweddle@hivma.org or 703‐299‐0915).  

Sincerely,  

Michael S. Saag, MD, FIDSA

Chair, HIV Medicine Association
HIV Medicine Association

Comments on Interim Regulations [OCIIO‐9994‐IFC]

August 26, 2010

Page 3

                                                           

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HIV Provider Experience and Patient Outcomes: Selected References:

AIDS mortality rates lower at sites with HIV experience. AIDS Alert 1999;14(11):129‐30.

Bach PB, Calhoun EA, Bennett CL. The relation between physician experience and patterns of care for patients with

AIDS‐related Pneumocystis carinii pneumonia: results from a survey of 1,500 physicians in the United States. Chest

1999;115(6):1563‐9.

Brosgart C, et al. Community patterns of care for HIV disease: experience makes a difference. Proceedings of Int Conf

AIDS 1998;12:1143‐44.

Brosgart CL, et al. Clinical experience and choice of drug therapy for human immunodeficiency virus disease. Clin

Infect Dis 1999;28(1):14‐22.

Hecht FM, et al. Optimizing care for persons with HIV infection. Society of General Internal Medicine AIDS Task  

Force. Ann Intern Med 1999;131(2):136‐43.

Kitahata MM, Van Rompaey SE, Shields AW. Physician experience in the care of HIV‐infected persons is associated   with earlier adoption of new antiretroviral therapy. J Acquir Immune Defic Syndr 2000;24(2): 106‐14.

Kitahata MM, et al. Physicians experience with the acquired immunodeficiency syndrome as a factor in patients’

survival. N Engl J Med 1996;334(11):701‐706.

Laine C, et al. The relationship of clinic experience with advanced HIV and survival of women. AIDS 1998;12(4):417‐ 424.

Landon, BE, et al. Physician specialization and the quality of care for human immunodeficiency virus infection. Arch

Intern Med 2005;165:1133‐1139.

Landon, BE, et al. Physician specialization and antiretroviral therapy for HIV: adoption and use in a national probability

sample of persons infected with HIV. J Gen Intern Med 2003;18:233‐241.

Markson LE, et al. Repeated emergency department use by HIV‐infected persons: effect of clinic accessibility and

expertise in HIV care. J Acquir Immune Defic Syndr 1998;17(1):35‐41.

Shapiro M, et al. Variations in the care of HIV‐infected adults in the United States. JAMA 1999;281: 2305‐2315.

Stone VE, et al. Relation of physician specialty and HIV/AIDS experience to choice of guideline‐recommended

antiretroviral therapy. J Gen Intern Med 2001;16: 360‐368.

Willard CL, Liljestrand P, Goldschmidt RH, Grumbach K. Is experience with human immunodeficiency virus disease

related to clinical practice? A survey of rural primary care physicians. Arch Fam Med 1999; 8(6):502‐8.

ii

  State of California, Department Of Managed Health Care Help Center, Division Of Plan Surveys,

Technical Assistance Guide. Accessed online 8/26/2010:

http://www.hmohelp.ca.gov/library/reports/med_survey/tag/fs_um_08_06_10.pdf