Viagra Spurs New Questions About HMO Drug Coverage

HMOs and health insurance companies, not exactly basking in the sunlight of public approval these days, have a new worry: Should they pay for Viagra?

The answer is yes, no and maybe, as the demand for the blue pill that enables impotent men to have erections makes it among the fastest-selling new drugs. Decisions on insurance coverage drift into the murky area where medicine, physical health, emotional satisfaction, sexual desire and morality collide.

If you are a man covered by Blue Cross of California, your health insurance will pay for six pills a month, provided you have a condition requiring the medication. For example, a man who is impotent because of diabetes, prostate problems, the side effects of blood pressure medication or some other condition can get a prescription. Why six guaranteed erections a month? That’s what was recommended by outside expert advisors. And who might these be? Psychologists, psychiatrists and doctors at leading teaching hospitals, according to Blue Cross.

Blue Shield of California, evidently using some of the same experts, also will approve six pills a month, prescribed and dispensed only on the grounds of medical necessity.

However, the management at PacifiCare does not yet recognize Viagra as an acceptable response to impotence. The medical directors for the health plan will meet at a national benefits committee this month to define medical necessity for Viagra and to write guidelines for physicians.

So far, all the HMOs and health insurers covering Viagra are saying a man has to have a specific medical condition to get the pill. But what if he has no identifiable organic problem, yet gets a referral from a psychiatrist or psychologist for Viagra on the grounds that his inexplicable impotence depresses him and harms his emotional health?

The prospect of spending lots of money on the magical blue pills without a concrete medical diagnosis makes medical plan managers quite nervous. “We don’t want to prescribe it just because a man is horny,” said an official of one health plan, who understandably asked not to be identified.

Then, for an otherwise healthy man, is Viagra a medical necessity or a “lifestyle choice”? After all, health insurance plans won’t cover cosmetic surgery for people who want eye tucks and face lifts. What about an unhappy man, now 50, who simply wants to restore the erectile performance he enjoyed in the bygone days of the Woodstock festival?

If men are getting access to Viagra, courtesy of their health plans, women should have their contraceptives fully paid for, says the Planned Parenthood Federation of America.

“With Viagra receiving almost instant coverage under many health insurance plans, there is no longer any excuse for insurers to exclude coverage for contraceptives,” said Gloria Feldt, president of Planned Parenthood. “Viagra means more sex. More sex means more need for effective contraception.”

Coverage varies considerably. More than 80% of HMOs include birth control pills and diaphragms as part of their regular coverage, compared with less than 40% of regular fee-for-service health plans, according to a recent survey by the Alan Guttmacher Institute. But coverage for IUDs and Norplant is much more unusual, with these contraceptive methods paid for by less than 50% of HMOs, and less than 30% of the fee-for-service plans.

About 70% of health plans will pay for abortions, and more than 80% routinely cover sterilizations and vasectomies, the survey indicated.

Infertility is another matter. Health plans will diagnose the causes of the problem. But what they do about it is quite different from plan to plan. Most will cover the drug clonimid, a treatment for infertility. But hardly any--only 17%--will pay for in vitro fertilization.

The arguments here focus on costs. Payment for in vitro fertilization raises the cost of health insurance higher than most corporate employers are willing to pay, health plan managers argue.

In the end, the insurance companies and HMOs are the middlemen moving dollars between payers and medical providers, reflecting society’s demand for care and its willingness to pay.

What kind of damage does a woman suffer to her emotional health because of infertility? And is that a condition that all health plans should deal with? How does a man’s despair because of impotence compare with a woman’s anguish over infertility? These are painful questions, and will become louder and louder with the aging of the baby boomers, the 76 million Americans born in the years from 1946 to 1965. In the end, their voices will determine what gets paid for by insurance, and how much must remain the financial burden of the individual.

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And now, switching from the cosmic issues to the concrete problems of our readers.

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Question: My daughter works for [an organization] that excludes her for existing conditions from a new medical plan. She was born without a right arm and a right foot, and the prostheses she wears cost about $15,000; plus, the gloves and special socks are quite expensive. Is there any type of state insurance that California offers that she can afford and is qualified to use?

Answer: The laws have changed, and your daughter can no longer be denied coverage where she works if other employees are covered by health insurance. The maximum waiting period for those with preexisting conditions is six months under insurance plans regulated by the state, and 12 months under plans regulated by the federal government. She should tell her employer that she is legally entitled to coverage like any other worker. Your daughter is entitled to get coverage at work, and cannot be charged more than any other employee for her health insurance.

In California, there is a special insurance pool for individuals with serious health programs who cannot get coverage at affordable prices. Typically, the people who use it are self-employed or do not have any reasonable coverage through work.

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Q: I have an issue with my previous employer, who did not inform me of the option for insurance coverage after my release from the company in January 1998. Currently I am still unemployed and without insurance. The company does not meet the federal criterion of 20 employees. My search for further information has met a dead end; few people know of the new law. Do you have any telephone numbers for state agencies that could assist me? Is there a possible legal issue, in that my past employer did not inform me of this particular insurance option?

A: Under California law, workers at firms with two to 19 employees offering health insurance coverage are entitled to continue coverage for 18 months after they leave the job. A worker would pay 110% of the cost of insurance--the full worker’s and employer’s share plus a 10% allowance for administration. You should have been notified by your employer or the insurance company that you have the right to continue coverage.

Your rights are protected under the California insurance code, section 10128.50. The Web site for information is https://www.insurance.ca.gov.

Talk to your former employer, or the insurance company or HMO that provided your health coverage. If they do not cooperate, complain to the insurance commissioner’s hotline at (800) 927-4357. Your coverage should be retroactive. If you have incurred medical bills since leaving the company, you should be reimbursed by the insurance plan.

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Q: Last year my 85-year-old mother broke her hip. The surgery went well, but one of the recommended nursing homes drugged her and she broke her other hip. She is now in an OK residency, an assisted-living facility in Hollywood. It charges $2,200 a month, and she pays $400 a month for drugs.

She now has about $40,000 in a savings account. Although she is in assisted living, she has a personal-care worker with her five hours a day. Because of her, my mother is thriving. The care worker costs $1,000 a month extra. We want to keep her. I have heard there is a trust you can set up whereby the patient can put aside money for personal use and apply for Medi-Cal. Can I do this now? What happens to the trust if my mother dies before she uses it up? Does it go to me and my brother or to reimburse Medi-Cal?

A: Medi-Cal, which pays nursing-home bills, would allow your mother to keep only $2,000 of “countable” assets. The trust you are considering is probably an irrevocable “special needs” or “supplemental needs” trust, and would not be a countable asset under Medi-Cal rules.

Medi-Cal would treat the money in a trust as if your mother were giving it away. This would be the same as if she gave the $40,000 to you. She would become ineligible for Medi-Cal for a period of time, depending on how much she puts into the trust.

You might consider a half-a-loaf solution, dividing the $40,000. Medi-Cal calculates the cost of a nursing home at $3,460 a month. If your mother puts $20,000 into the trust, she would be ineligible for Medi-Cal for five months ($20,000 divided by $3,460, and rounded down). The remaining $20,000 she has would pay her bills at the assisted-living facility, including her personal care worker, for about six months.

When your mother’s assets get down to $2,000, she can go into a nursing home and be eligible for Medi-Cal payments. And the $20,000 in the trust will be available to pay for the personal care worker and any other costs not covered by Medi-Cal at the nursing home.

Your mother can make you and your brother beneficiaries of the trust. If she dies before the money is used up, you will receive it. Medi-Cal would not have a claim on the money.

But this is a complex area--don’t take this discussion as final and definitive. Before doing anything, you should consult an elder-law attorney. Call the local bar association or California Advocates for Nursing Home Reform, (415) 474-5171, for a referral to someone who specializes in these issues. A consultation for an hour or two should get you enough useful information to make the decisions. And make sure your mother is involved. After all, it’s her money and her life.

Tip of the Month: The federal government’s authoritative “Guide to Choosing a Nursing Home” is available by calling (800) 638-6833.

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This column appears every second Monday in Health. Send your questions, worries, tips, successes or failures in living with the health insurance revolution to Benefits Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053. Or e-mail: Bob.Rosenblatt@latimes.com.