“We will voluntarily agree to set an out-of-pocket limitation of $200 per month on each of the following drugs: Atripla, Complera, Stribild, and Fuzeon,” Preferred Medical Plan CEO Tamara Meyerson wrote to Kevin McCarty, commissioner of the Florida Office of Insurance Regulation, in a Jan. 14 .

The other three companies — , and — had earlier reached formal agreements with state regulators to lower their prices and to fill prescriptions without prior authorization for 2015.

Preferred did not violate Florida’s anti-discrimination laws, said Amy Bogner, a spokeswoman for the state’s insurance office.

The four Florida insurers were the focus of a federal civil rights complaint filed last May by , a nonprofit group in Tampa. The complaint accused insurers of discriminating against people with HIV by making their medications too expensive — as much as $1,500 per month for drugs on some health plans offered in Florida last year.

The U.S. Department of Health and Human Services is still investigating the complaint, according to spokeswoman Rachel Seeger.

Carl Schmid, deputy executive director of The AIDS Institute, said he was disappointed the state did not ask Preferred to sign a more extensive agreement.

“What’s in the letter is really nominal,” Schmid said. “It doesn’t even say how long Preferred has to abide by these terms.”

But David Poole, a spokesman for the , which worked with state regulators on the drug pricing issue, called the letter “acceptable” and said all insurers should ensure antiretroviral medications are “accessible and not economically out of reach.”

The news comes as Gov. Rick Scott confirmed that he was McCarty, who has led Florida’s insurance regulator since 2003.

AHF yesterday sent a to the governor praising McCarty’s work on the pricing of HIV drugs.

“The actions of the commissioner and his staff assured … that public health in Florida would not suffer because of the restrictive actions the private insurance companies had instituted,” the letter said.

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At the same time, 56 percent of local hospitals performed better than expected in controlling infections, according to the same data, information that South Florida consumers could use when choosing a hospital.

The ratings are part of a national effort to cut down on the most common infections patients contract in the very places they go to get well: hospitals.

The federal government has also taken action in the form of financial penalties. In 2008, Medicare stopped reimbursing hospitals for treating patients who acquired infections under their care. This year, as part of the Affordable Care Act, Medicare will hospitals that fail to meet standards on a variety of patient safety measures, including infections.

Steven Ullmann, a health policy expert at the University of Miami, called the penalties “significant” and said they had helped push hospitals to fight infections.

More than 3,300 hospitals around the nation reported data to the Centers for Disease Control and Prevention on six types of common healthcare-associated infections contracted by patients in 2013.

One Miami institution, North Shore Medical Center, performed worse than all but five hospitals nationwide.

In South Florida, the CDC collected data from 32 hospitals in Miami-Dade, Broward and Monroe counties. Thirteen of those hospitals, or 41 percent of the South Florida total, failed to meet national benchmarks in at least one infection category, compared with 30 percent of hospitals statewide and 23 percent nationally.

“Any place in the country that finds its hospitals are lagging in an important area like infection rates needs hospital leadership to devote resources to address the problem,” said Robert Brooks, a patient safety expert who served as secretary of the Florida Department of Health between 1999 and 2001.

One in 25 patients in the hospital on any given day will contract an infection, according to the CDC, which also reported that from hospital-acquired infections.

In Miami, North Shore Medical Center performed worse than CDC standards in controlling four types of infections, one of only six hospitals in the nation to fall below national standards in that many categories. No hospitals underperformed in five or more categories.

Holy Cross Hospital in Fort Lauderdale performed well during the 2013 assessment, doing better than CDC standards in four infection categories, the most of any hospital in Florida. But recent data — not yet released to the public — shows that Holy Cross’ performance dropped in 2014 to an “average” rating in all four categories, according to Christine Walker, a spokeswoman for the hospital.

Brooks, the patient safety expert, said the publication of such data is a crucial resource for consumers.

“As younger patients age and require more services, they’re going to be more computer savvy and the ability to find out more about their hospital or their doctor online will be extremely helpful in helping them make decisions about their medical care,” he said.

The infections measured by the CDC data are catheter-associated urinary tract infections, central line-associated bloodstream infections, C. diff intestinal infections, MRSA bloodstream infections and surgical site infections that develop after hysterectomies or colon operations.

The CDC takes mitigating factors such as the size of a hospital and whether it serves as a teaching institution into account when compiling its ratings, but some hospitals say this risk adjustment doesn’t fully capture their type of patients and the services they provide.

“Larger hospitals and those that have the resources to aggressively diagnose infections tend to be penalized by these data,” said Nancy Foster, vice president of patient safety at the American Hospital Association. “And the data are a bit behind the current state of events because of how long they take to compile.”

“The important thing for the public to understand is that hospitals are working very hard all across the country to improve their performance,” Foster said.

At Mount Sinai Medical Center in Miami Beach, hospital officials have seen progress. Previous numbers covering parts of 2012 and 2013 showed that Mount Sinai national standards in combating two types of infections: surgical site colon infections and MRSA.

But for 2013, the hospital had improved its performance to average in MRSA. It also performed better than national benchmarks for preventing urinary tract and C. diff infections.

“It’s an extra expense for the hospital, it’s extra work for our staff, but we know it’s really important to eliminate these kinds of infections,” said Dr. Robert Goldszer, chief medical officer at Mount Sinai Medical Center in Miami Beach.

Goldszer said last year the hospital increased its use of chlorhexidine, the antimicrobial liquid soap, for its highest-risk patients, including patients undergoing surgery and those in the intensive care unit.

The hospital also uses antibiotic-coated intravenous catheters for acute care.

“Some of this is technique, but a lot of it is education,” Goldszer said. “Our staff knows that every day this has to be a major priority.”

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But the new managed care system is also exposing some Floridians in Medicaid, the state/federal insurance program for children, the poor and disabled, to the uncertainties of the private market for the first time.

Malissa Miller, a Medicaid recipient born with a rare and deadly intestinal condition called Hirschsprung’s disease, thought for months that she would have to move from her Broward home to another county in order to receive the treatment she believed would save her life.

She says her insurer repeatedly told her she could not visit a renowned gastroenterology clinic at the University of Miami because it was not included in the insurer’s provider network.

Other insurers in Miami-Dade and Palm Beach counties — the two counties a few miles to the south and north — offered plans that would pay for Miller’s treatment at the UM clinic.

As part of Medicaid managed care, insurers choose which counties to sell plans in. None of the four insurers providing coverage in Broward included the clinic in their networks.

Hours after the Miami Herald called the insurer, Sunshine Health, to inquire about her case, Miller says she was told she could now visit the clinic.

“I’m over the moon,” Miller said. “I’m praying they can help me.”

In a statement to the Herald, Sunshine said that it had given Miller special permission to seek treatment at the clinic in October. “Our main focus is ensuring this member gets the services she needs,” wrote Alia Faraj-Johnson, a spokeswoman for the company.

She did not address questions about how or whether Miller could have misunderstood the options available to her. Faraj-Johnson also said Sunshine would include the clinic in its network as of Jan. 1.

Patricia Meyer, Miller’s sister-in-law and healthcare surrogate, said she spent weeks trying to convince a case manager at Sunshine that Miller needed to continue treatment at the clinic after a promising initial visit in September, when she was still covered under a previous Medicaid insurance plan.

“They just would not listen,” Meyer said.

Meyer said the company, which is owned by Missouri-based Centene, refused and told Miller to seek treatment with its in-network GI specialists in Broward. But Miller didn’t like the doctors. She felt that her best hope lay with the UM clinic — and she didn’t want to relocate to one of the counties where the clinic would be covered.

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The Centers for Disease Control and Prevention tracks how hospitals around the nation perform on preventing six types of frequently occurring infections, including bloodstream and urinary tract infections that result from catheters and surgical site infections that develop after colon and hysterectomy operations.

North Shore Medical Center did worse than national standards in controlling four types of infections.

Only one other Florida hospital, UF Health Jacksonville, a teaching hospital in Duval County, underperformed the CDC benchmarks in more than two categories, and only seven hospitals in the nation underperformed in four categories.

Cristy Martinez Paez, a spokeswoman for North Shore Medical Center, wrote in an email that the hospital provides “high-quality patient care” and is engaged in an “ongoing effort to reduce hospital-acquired infections by implementing proven methods such as a comprehensive safety program on every unit.”

She wouldn’t provide details of the safety program, saying only that “we continue to work toward a goal of zero cases.”

Bruce Rueben, president of the Florida Hospital Association, a trade group, said hospitals in the state were working together to find effective strategies for reducing infections and other hospital-related injuries like falls and medication overdoses. Patients and providers would benefit from focusing on the problems, Rueben said, in part because hospitals have higher treatment costs when patients develop complications under their care.

The federal government compiles scores for individual hospitals based on a broad range of patient safety measures, including hospital-acquired infections.

In December, the government will announce the first round of , assessed through Medicare payments, for hospitals with low safety scores. The program was established as part of the Affordable Care Act.

The government is also expected to release updated infection rates for hospitals by the end of December.

Standardizing procedures that nurses and doctors perform on patients can help prevent infections, said Dr. Robert Goldszer, chief medical officer at Mount Sinai Medical Center in Miami Beach.

“More variation means more opportunities for things to go wrong,” Goldszer said. “We’re trying to design the easiest way to provide our patients with the right care all the time.”

Mount Sinai performed worse than national benchmarks in preventing MRSA and post-surgical colon infections but exceeded for urinary tract and C. diff infections.

Goldszer said Mount Sinai had worked with the Florida Hospital Association and other healthcare institutions to identify ways to improve its fight against infections including increased hand-washing, special soaps to clean a patient’s skin before surgery, avoiding the over-use of catheters and investigating how every new infection occurs.

He said the hospital had reduced the frequency of colon infections from 20 cases in 2013 to five as of September this year, and had also seen a moderate drop in its rate of MRSA infections.

“We need to continuously measure and assess our progress,” Goldszer said.

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As part of its agreement with the Florida Office of Insurance Regulation, Cigna will cap the amount consumers pay for four popular HIV drugs — Atripla, Complera, Stribild and Fuzeon — at $200 per month. Previously the company asked consumers to pay a co-insurance of 40 to 50 percent of the drugs’ cost.

Cigna will also move generic HIV drugs from its most expensive specialty “tier” to a less expensive tier for generics. And it will no longer require consumers to seek “prior authorization” from the insurer to refill their prescriptions.

The agreement said that Cigna had entered into the consent order, in part, to “avoid litigation.”

In May, two civil rights groups filed a complaint with the federal government accusing Cigna and three other Florida insurers of discriminating against people with HIV.

The complaint, lodged with the U.S. Department of Health and Human Services, said the four companies made lifesaving HIV drugs so expensive that they prevented consumers “from enrolling in those health plans — a practice which unlawfully discriminates on the basis of disability.”

Cigna denied all wrongdoing in the consent order, which also stated that Florida regulators made “no finding” about whether the company’s practices violated state or federal law.

In October, the Miami Herald wrote about among Floridians with HIV that they would not be able to afford prescriptions under plans offered on the federal marketplace for health insurance, which opens Nov. 15.

Carl Schmid, deputy executive director of the AIDS Institute, one of the groups that filed the federal complaint, called the agreement a “good first step,” but said it should have gone further.

“We’re glad that Cigna recognized they had problems with the way they designed their plans and how it affects people with HIV,” Schmid said.

But he added that the cap on out-of-pocket monthly expenses should have been expanded to include more drugs. Schmid also said that Cigna should offer customers a 90-day supply of its medications, rather than the minimum 30-day supply agreed to in the consent order.

Karen Eldred, a spokeswoman for Cigna, wrote in a statement to the Herald that the insurer had voluntarily agreed to the changes in order “to offer customers quality, affordable care.”

HHS is still investigating the issues raised by the federal complaint, spokeswoman Rachel Seeger confirmed.

In the consent order, state regulators said they had been provided with a copy of that complaint, which also named CoventryOne, Humana and Preferred Medical as discriminating against people with HIV.

Amy Bogner, a spokeswoman for the state Office of Insurance Regulation, would not comment on whether it was negotiating consent orders with the other companies or planning to pursue litigation against them.

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Now Smith, 42, of Coral Springs, has been told he must sign up for coverage on Florida’s federally run insurance exchange or the state will stop helping him pay his premiums.

“The landscape of healthcare has changed, and with the passage of the Affordable Care Act we have the opportunity to access and enroll in cost-effective health plans,” an official at the AIDS Insurance Continuation Program wrote in a letter to Smith and other AICP beneficiaries.

But it is not clear that ACA insurance plans will be cheaper — or even affordable — for those with HIV and AIDS, according to patient advocates.

Last spring, two nonprofit groups filed a federal civil rights complaint alleging that some Florida insurers were discriminating against people with HIV by charging “inordinately high” rates for HIV medication on ACA plans.

In their complaint, the AIDS Institute and the National Health Law Program singled out CoventryOne, Cigna, Humana and Preferred Medical for discouraging people with HIV “from enrolling in those health plans — a practice which unlawfully discriminates on the basis of disability.”

The ACA prohibits insurers from discriminating against consumers because of preexisting medical conditions. The four companies all offered 2014 plans in Florida, including in Miami-Dade and Broward counties, and plan to do so again in 2015, with the exception of Preferred Medical in Broward.

It is an important issue for Florida, which has the third-highest rate of HIV infection in the nation, and for Broward and Miami-Dade, which have the highest rates statewide. Almost 95,000 people in Florida have been diagnosed with HIV. Many of them have coverage for the first time thanks to the health law, activists say. But without proper regulation, high drug prices could act as a de facto form of discrimination, said Carl Schmid, deputy executive director of the Tampa-based AIDS Institute, one of the groups that filed the civil rights complaint.

In a statement to the Miami Herald last week, Coventry spokesman Walt Cherniak said the insurer’s 2014 plans provided access to HIV care “that follows the latest Department of Health and Human Services guidelines and evidence-based practices.” Humana, Preferred Medical and Cigna also issued statements to the Herald denying any discrimination. Humana said it places HIV drugs on its highest — and most expensive — tier because of their cost and clinical complexity.

The details of 2015 insurance plans on the federal exchange in Florida will not be announced until early November, leaving Smith and other Floridians with HIV in limbo. Open enrollment will begin Nov. 15.

“I’m drowning in paperwork trying to figure out what sort of plan I’ll need,” Smith said. “And I’m really worried that I’m just going to be stuck if enrollment opens and there aren’t any I can afford.”

And what if Healthcare.gov, the enrollment website, is again derailed by the kinds of problems that marred its introduction, preventing people from signing up for coverage for months? “I don’t even want to think about that,” Smith said.

HHS said the complaint, filed in May, is still under review by its Office for Civil Rights, which protects consumers from discrimination. The complaint asked the OCR to prevent the four companies from offering plans with discriminatory costs.

Harvey Bennett, a spokesman for the Florida Office of Insurance Regulation, said the state was also investigating whether the plans were “unfairly discriminatory.”

Not all insurers on the exchange are being accused of discrimination. Aetna, Ambetter and Molina placed most of their HIV drugs on less-expensive tiers. Florida Blue, the state’s largest health insurer, listed all but one HIV drug on lower tiers requiring monthly co-pays of $10 to $70.

But the market has seen a general trend toward plans with high deductibles and high co-insurance models for expensive drugs, including those for hepatitis C and multiple sclerosis, according to Steven Ullmann, director of the Center for Health Sector Management and Policy at the University of Miami’s School of Business Administration.

Ullmann said cost-sharing presents a moral dilemma. “It’s one thing if you’re dealing with an elective pharmaceutical, but it’s another where you’re looking at drugs and treatment plans that affect one’s ability to sustain quality of life,” Ullmann said. “But insurance companies are businesses, as well, and one recognizes their incentive structure: to avoid taking on too much risk.”

Ullmann said companies that offered low-cost HIV drugs last year may change their behavior this year based on the plans of their competitors. That means that until insurers reveal their rates for 2015, Smith and others with HIV will not know whether plans will place HIV drugs in high- or low-cost tiers.

“What we’re really worried about is a race to the bottom,” said Wayne Turner, a staff attorney at the National Health Law Program, which helped file the civil rights complaint. Turner said he fears the high-cost plans may have “skewed the market” and that in order to avoid having their risk pool burdened by people with expensive health needs, competitors may increase what they charge for HIV drugs.

Some of the ACA plans have other drawbacks, such as limiting patients to a 30-day supply of medicine instead of a 90-day supply and requiring prior authorization from insurers before every refill. A 2012 conducted by the pharmacy chain Walgreens and published by the Centers for Medicare and Medicaid Services, which regulates plans sold on the exchange, found that patients with 90-day supplies took their medicine more regularly and had greater cost savings than those with 30-day supplies.

Turner said that with the confusion of the exchange’s launch out of the way, the time was right “for the federal government to send a strong message to plans that they can’t design their benefits in a way that discriminates against people with HIV.”

In a statement to the Miami Herald, Aaron Albright, a spokesman for CMS, called the law’s anti-discrimination provisions “effective” and said the federal government was investigating complaints of discrimination.

Smith said he wouldn’t mind switching to the ACA if he knew that plans with sufficient coverage were waiting for him.

But he knows he will be in trouble if all of the plans look like one Humana plan from last year mentioned in the complaint. The terms of the “silver,” or mid-range, plan would require him to meet a $1,500 prescription deductible and then pay 50 percent of his total drug costs. For his Atripla prescription, a once-daily anti-retroviral, that would mean a monthly payment of around $1,000 until he hit his $6,300 out-of-pocket limit.

“That’s just such a crazy jump from what I’m paying now,” said Smith, who is currently covered by an off-exchange Cigna plan. “I’m already trying to save by not going to the doctor for minor stuff.”

Right now, AICP, the program that helped Smith keep his insurance when he was laid off, pays $750 of his $803 monthly premium. He is responsible for a monthly $110 co-pay for medication. Without insurance, Atripla costs more than $6,300 every three months. AICP, Smith said, “saved my life.”

The program receives about half of its funding from the federal Ryan White HIV/AIDS Program, which helps provide medical care for about 500,000 HIV-positive people nationwide. By federal law, the Ryan White program is the “payer of last resort,” meaning many Floridians who can get cheaper coverage from another source, such as an ACA exchange, will now be required to do so.

Other HIV-positive patients will also be funneled to the exchange, including some clients of the state-administered AIDS Drug Assistance Program, which helps pay for HIV drugs for people who have low incomes or little or no insurance. The program receives 90 percent of its funds from the Ryan White program, meaning that those whose medication costs can be reduced by going onto an exchange will have to do so.

Nathan Dunn, a spokesman for the Florida Department of Health, said that this year about 4,000 of the 14,000 people enrolled in ADAP will have to sign up for federal marketplace coverage. The state would be in danger of losing its Ryan White program funding if it did not move people onto the exchange.

At the Legal Aid Society of Palm Beach County, which helps Ryan White program clients, staff attorney Vicki Tucci said many consumers with HIV who enrolled last year were unhappy with their plans. Tucci counseled about 30 people with HIV who said they discovered too late that the insurance plans they had purchased either didn’t offer enough coverage to make their HIV medicines affordable or didn’t include long-time healthcare providers in their network.

“These were people who were often signing up for health insurance for the first time,” said Tucci, who served as a marketplace “navigator” assisting new enrollees last year. She said she was able to help about half of the 30 clients who came to her switch plans.

For his part, Smith is trying to educate himself about the best way to pick a health insurance plan.

He has learned that low premiums are often accompanied by high deductibles and high co-insurance rates, and he plans to talk with a navigator who can guide him through the system. But he worries that others with HIV might not be as well-prepared.

“There are people out there who, if they don’t do their homework, they’re really going to get sucker-punched [next year] when they start paying their bills,” Smith said.

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