"ADA May Widen HIV Coverage"

Important note: Information in this article was accurate in 1992. The state of the art may have changed since the publication date.

"ADA May Widen HIV Coverage"

National Law Journal (12/21/92) Vol. 15, No. 16, P. 26
Rumeld, Myron D. and Brook, Richard

Abstract: Health plan sponsors and fiduciaries have resorted to provisions limiting coverage for certain types of illnesses or treatments in an effort to control rising costs. Caps or restrictions on coverage for the treatment of AIDS or HIV have become particularly common despite the dramatic increase in claims for HIV-related care and the potential effect of such claims on the financial stability of many health plans. The Americans with Disabilities Act, designed to prohibit discrimination against employees with disabilities, will give claimants a more effective legal weapon. But the Employee Retirement Income Security Act of 1974 (ERISA) gives broad discretion to plan sponsors and fiduciaries to determine how best to control plan costs. Plan fiduciaries may cite policies and considerations that are not cost-based when defending plan rules limiting coverage for HIV treatment. For instance, some plans deny coverage for the treatment of drug abuse, and on that basis might deny coverage for HIV patients when the evidence indicates that the virus was contracted through drug abuse. The exact impact of the ADA on rules capping coverage will depend, however, on the construction of vague and conflicting provisions of the statute and its underlying legislative history. The ADA does not directly prohibit restrictions on HIV coverage, but it may indirectly do so by opening the door for state law challenges that until now have been considered pre-empted by ERISA. Until the uncertainties prompted by passage of the ADA are resolved by the courts and the Equal Employment Opportunity Commission, many plans are likely to choose other means of controlling costs.

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