Labwork : Who's Got You Covered? - by Staff

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Back to home » HIV 101 » POZ Focus » Labwork

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Blood Simple

Resistance Testing

CD4 Count

Viral Load

CBC

Chem-Screen

Who's Got You Covered?

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Who's Got You Covered?

by Staff

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).



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