Lab work doesn’t come cheap. KARIN TIMOUR tells you how to work the system
Viral
load test: $150–$200. CD4 cell count: $65–$125. Genotypic drug
resistance test: $250–$600. Phenotypic test: $750–$1,100. You do the
math: Unless your last name is, say, Quest, you’re going to need some
deep pockets to help pay for these standard HIV tests—some that you’ll
get as often as four times a year. The good news is that most insurers,
along with state and federal programs, cover most tests.
Health
insurance. All private insurers these days will pay for CD4 count and
viral load tests, and most will cough it up for you to check for drug
resistance. Typically, the cheaper genotypic test is easier to get, but
of the six major insurers POZ polled, all cover phenotypic testing if
your doctor orders it. There’s also a combined genotype-phenotype test
that is often cheaper than running each one separately.
If you’re insured through
your employer, you should get a free ”summary plan description“ that
details the coverage and clarifies if the plan is “insured” or
“self-insured” (see below). Then call your insurer or visit its website
with questions about specific tests. For example, Aetna has searchable
”Coverage Policy Bulletins” on its site—and when you type in HIV drug
resistance tests, you get a clear statement of the policy. Knowing in
advance will save you any nasty surprises on the bill.
Your
doctor is a resource, too. HIV specialists order these tests
constantly, so they often know which plans pay for what. If you’re
comparison shopping for insurance, ask your ASO, support group or
friends. Use the grapevine.
Self-insured plans. An HIVer who
works for a company that employs 1,000 people or more likely has
self-insurance. Surprise! Rather than buying a policy to cover the
staff, your employer pays employee health claims directly—either by
subcontracting administration of the plan to an insurance company or
setting up an internal department overseeing the details. If the
latter, should you be freaked that Joe Blow in the stock room might be
deciding which tests you can get? No, says Mark Scherzer, a New York
City benefits attorney. “The plan administrator will rely on expert
medical opinions, though their quality can be uneven.”
Medicare. If you have a long-term disability
or are over 65, you’re covered by this federal program—which pays for
routine blood work, CD4 cell counts, viral load tests and both kinds of
drug resistance tests.
Medicaid.
Run jointly by the feds and the
states, the eligibility and covered services vary widely from state to
state. Contact your local
Medicaid office for answers—you’ll find a complete list of numbers on
the AIDS Treatment Data Network’s (ATDN) Access Project
(e-mail them at theaccessproject@atdn.org or call 212.260.8868).
ADAP
and Ryan White funds. Every state has an AIDS Drug Assistance Program
(ADAP), which covers lab work as well as drugs; some states have
special Ryan White funds to pay for viral load and resistance tests
even if you don’t qualify for ADAP. To find out if you’re eligible, ask
your HIV clinic or get your state’s ADAP number from the ATDN.
What
if they won’t pay? Appeal the decision—with your doc’s help.
Notorious skinflints, insurers routinely reject perfectly correct
claims—or demand that you resubmit—only to accept them later. Most
states have review organizations that can reverse these decisions;
Medicare and Medicaid have review rules as well. In California, you can
file a complaint with the Department of Managed Health Care's HMO Help Center (go to
www.hmohelp.ca. gov/gethelp or call 888.HMO.2219); in New York, file
complaints with the State Insurance Department (www.ins.state.ny.
us/complhow.htm. or 800.342.3736).
