It’s time for round two. The Affordable Care Act (ACA), also known as Obamacare, will have its second open enrollment period from November 15 through February 15, 2015. This means that Americans are free to shop for a new health insurance plan. And because the ACA outlawed pre-existing condition exclusions, people living with HIV no longer have to worry about being rejected for coverage or charged more for premiums because of their serostatus.

You can obtain a private plan through the insurance marketplace, also known as the insurance exchange. Or, if you are low income and live in one of the 27 states, along with Washington, DC, that have opted to expand Medicaid as a part of the ACA (the Supreme Court has given state governments the option not to), you can seek coverage through that government program. In fact, you can apply for Medicaid at any time.

Note however that some states, such as Arkansas, have expanded Medicaid to allow the program to purchase private health plans on your behalf. Check with the marketplace in your state to see if this is available to you.

(Throughout this article you can click on any of the highlighted words for links to more information and other online resources.)

If you are already enrolled in an Obamacare plan, you may also use this period to compare your plan with others on the market and to switch to another if you prefer. Insurance experts strongly encourage you to weigh your options, because details of your plan may change in 2015 and there may be better alternatives.

The ACA requires all eligible Americans to get health coverage. In 2015, those who do not are subject to a fee of either $325 per adult and $162.50 per child (up to $975 for a family), or 2 percent of a family’s annual income, whichever is larger. In 2016 the fee will increase to $695 per adult, or 2.5 percent of family income.  You may qualify for an exemption, however—for more information, click here.
Coverage for new marketplace plans will start as early as January 1, 2015, when you sign up by December 15. For the remainder of the open enrollment period, coverage begins on the first day of the following month if you sign up between the 1st and 15th of the month. And if you sign up between the 16th and the last day of the month, coverage begins on the 1st day of the second following month. The latest that coverage will begin is March 1, 2015.

For those with smaller incomes, subsidies are available to help pay the monthly premium costs for the marketplace plans offered in each individual state. And most residents of states with expanded Medicaid who make less than 138 percent of Federal Poverty Level (FPL) will qualify for the expanded system.

Andrea Weddle, executive director of the HIV Medicine Association, encourages HIV-positive people to seek assistance choosing a plan. It can be tricky to determine which plan is best suited for the needs of someone living with the virus. Plus, the AIDS Drug Assistance Program (ADAP) can only help cover costs for certain plans, so it helps to have expert guidance on identifying these plans. Be sure to connect with your local AIDS service organization for information on how you can get assistance.

Note that the ACA does not extend these insurance benefits to undocumented immigrants.

Where to begin:

Get assistance:

The ACA provides funding to train people who will assist you in selecting a health plan. Make sure you get in contact with someone who is trained to help people with HIV. Your local AIDS service organization is a good place to start. Click here for more information on assistance, or check your state’s insurance marketplace website. Click here for assistance geared toward the LGBT community.

Get the ball rolling:

The place to learn about your options and, come November 15, to begin the application process, is Yes, that’s the Federal website that had all the problems the first go-round. But it has been thoroughly revamped and should now be much more user-friendly. The website acts as a portal to information on available plans. If you live in one of the states with its own insurance exchange program, will direct you to that program’s website. The same holds true if you live in a state with an expanded Medicaid program—check out this page. If your state is using the federally run insurance exchange, you’ll be able to apply for a marketplace plan directly through

What’s your income? Do you qualify for Medicaid or private insurance?

Income is defined as your expected “modified adjusted gross income” in 2015. For most people this is the last number on the first page of your 1040 federal tax return. The figure factors in certain deductions such as business expenses, IRA contributions, student loan interest, moving expenses and health savings account contributions. You’ll have to estimate your income and deductions for 2015.

If your modified adjusted gross income is less than 138 percent of FPL—in 2014, that’s $16,104 for an individual and $27,310 for a family of three—then you will probably qualify for the expanded Medicaid coverage. You will not need an AIDS diagnosis to do so. (See this chart for 2014 FPL figures by family size, and then multiply the first column by 1.38. The 2015 figures, which will likely be somewhat higher, haven’t been released yet.) You can only access expanded Medicaid if you live in one of the 27 states, as well as Washington, DC, that have opted to develop such programs.

If you live in a state that has not expanded its Medicaid program and you are otherwise eligible with an income under 138 percent of FPL, you are exempt from the fee charged to those who do not obtain insurance in 2015. Unfortunately, due to a loophole in the law, there are no federal subsides available to help pay for marketplace premiums for those with incomes below 100 percent of FPL who live in states with no expanded Medicaid.

Anyone younger than 65 who does not have access to insurance through Medicaid, Medicare or your employer may purchase one of the various private health plans through the new health insurance marketplace system, sometimes known as insurance exchanges. And even if you do have access to insurance through your employer, if your monthly premium costs more than about 9.5 percent of your income, you may still be able to receive subsidies and purchase a plan on the marketplace. For more information on marketplace plans and to be directed to your state’s website—if you live in a state with its own marketplace system—click here.

How much will this cost me?

For a chart determining whether you qualify for health care tax credits, lower out-of-pocket costs or low-cost health care through Medicaid, click here.

ADAP may help defray costs:

ADAP is known as “payer of last resort,” meaning that if there is any other source that can pay for health coverage for people with HIV, that source must be prioritized. However, ADAP may still be able to help pay for premiums or other cost sharing, such as co-pays, involved in marketplace health coverage. Check with your state ADAP program for more information.


Cost sharing in Medicaid programs varies by state. The ACA gives the states the option to charge premiums, deductibles and co-pays. However, any out-of-pocket costs can’t exceed 5 percent of your family income. For the state expanded Medicaid program’s list of preferred drugs, they can charge up to $4 and for non-preferred up to $8. An outpatient visit to the doctor can cost up to $4 for those making less than 100 percent FPL and up to 10 percent of the cost Medicaid pays for those with larger incomes. However, those earning up to 100 percent of FPL can’t be denied services for their failure to pay.

Marketplace plans:

Information about marketplace health care plans and their estimated costs should become available in early November.

As was the case in 2014, insurance exchange plans are priced on a “medal tier” system, with each representing an average percentage of medical expenses consumers will be responsible for through cost sharing: bronze (60 percent average cost sharing), silver (70 percent), gold (80 percent) and platinum (90 percent). There are caps on cost sharing, and each plan has an annual out-of-pocket expense cap. The lower tiers have smaller monthly premiums but have higher cost sharing per service or treatment. Meanwhile the top tiers have higher premiums and less cost sharing.

In general, people with HIV, who typically have very high medical expenses, will pay the least money overall if they go with a platinum plan. A major exception is the fact that those earning between 100 percent and 250 percent of FPL ($11,670 to $29,175 for individuals in 2014 dollars) qualify for cost-sharing assistance with silver plans. Additionally, for people with incomes up to 250 percent of FPL, marketplace plans must lower the cost for certain essential health benefits.

If your modified adjusted gross income for 2015 is between 100 and 400 percent of FPL (2014 figures are $11,670 to $46,680 for an individual and $19,790 to $79,160 for a family of three), tax credits are available to subsidize your monthly premium in any of the plan tiers. If you already have a marketplace plan, the subsidy amount will rise somewhat along with the new FPL figures. You can have this credit paid directly to the plan to lower your monthly premium bill, or you can receive the money in a lump sum when you file your 2015 taxes. However, if you select to have the credit paid directly to the plan and your 2015 income ends up being higher than what you estimated when you started the plan, you may wind up owing money. For a rough estimate of your premium costs, factoring in a potential tax subsidy, use this calculator. For more information on premium subsidies and how they are calculated, click here. (Note that sometimes charts will list 133 percent FPL as the cutoff for Medicaid eligibility, but in actuality there is a 5 percent buffer on top of that figure, which is why the figure is stated as 138 percent in this article.)

For more information on subsidies, click here.

Can I be charged more for having HIV or for other lifestyle factors?

Your health status will not change the cost of your marketplace insurance premium. Tobacco use, however, may subject you to very substantial surcharges—up to a 50 percent increase. For information about quitting smoking, click here. Marketplace plans can also charge higher premiums based on family size, age and location, but not for your sex or health status.

Will I be rejected for coverage because I have HIV?

No. Since January 1, 2014, it has been against the law for any insurer, including Medicaid, to deny coverage to anyone because of a pre-existing condition or to cancel your insurance for any health problem that may arise. The ACA bans both annual and lifetime caps on insurance coverage.

Will my plan pay for my antiretroviral regimen?

By law, each plan at a minimum has to cover at least one drug in each of four therapeutic classes: nucleoside reverse transcriptase inhibitors (NRTIs, or “nukes”), non-nucleoside reverse transcriptase inhibitors (NNRTIs, or “non-nukes), protease inhibitors (PIs) and “other,” a category which includes Fuzeon (enfuvirtide), Isentress (raltegravir) and Selzentry (maraviroc). Depending on the state, the coverage tends to be far broader than just a single drug in each class. Some marketplace formularies in 2014 have not covered single-tablet regimens.

The expanded Medicaid programs operate their drug formularies similarly to the insurance marketplace plans.

A major problem that has arisen in 2014 has been that marketplace plans often require high cost sharing for ARVs. Some plans have placed all HIV drugs, including generics, on the highest co-pay tier. There are lawsuits pending that accuse insurance companies of discrimination against HIV-positive people for these pricing schemes.

Consequently, it is vital to research a potential plan’s formulary to see which drugs are covered and how much they will cost you. There should be a link to each plan’s formulary online, as well information about cost sharing. If the co-pays are very high, check with your state ADAP program for help, or click here for information about co-pay assistance from pharmaceutical companies. In addition, a group called Speak Up! is seeking information about problems people with HIV are having with the ACA, including experiences with high cost sharing.

Checking provider networks.

When you’re shopping for health plans, make sure to check each plan’s provider network to see if you’ll be able to see the specialists you need. Information on the networks should be available online through or your state’s insurance marketplace website. These directories can be incorrect or out of date, however, so it’s a good idea to call a doctor’s office or clinic directly to double check that they will take that insurance.

Shopping Around.

If you are already insured through a marketplace plan, experts urge you to comparison shop to make sure you’re getting the best deal and have the greatest access to health care providers. has a page where you can start this process if your state uses the federally run insurance marketplace; otherwise, the site will direct you to your state’s marketplace. Keep in mind that your current plan’s provider network, cost-sharing details or formulary may change in 2015. So be vigilant about how such changes might affect you.

Automatic re-enrolling or canceling your old plan.

If you are enrolled in a marketplace plan, you will most likely be automatically re-enrolled and should be receiving a letter from your insurance company stating this. So if you prefer to stay in that plan for 2015, you won’t have to do anything.

If you prefer to switch plans, so long as you go through or your state insurance marketplace website, your old plan should be canceled automatically. However, if you contact an insurance carrier directly to obtain marketplace coverage, you should also contact your old carrier to let them know you are canceling your plan.

For more information on automatic re-enrollment or switching plans, click here.

Adjusting your subsidy for 2015.

If you already have a marketplace plan and are receiving a federal subsidy, you may want to revisit or your state’s insurance marketplace website to adjust your expected income for 2015 in order to get the right subsidy. You should also report life changes, such as getting married or having a child, as this will affect your subsidy calculation.

Married to a Same-Sex Partner?

If you are legally married to a same-sex partner, starting in 2015 all insurance plans must offer the same benefits to you and your spouse as they do to opposite-sex spouses. This is true regardless of where you live, meaning that if you were married in a state where same-sex marriage is legal but live in one where it is not, you will still have these health insurance rights.

Get on your parents’ insurance.

If you’re age 26 or younger, you can get coverage through your parents’ insurance plan. So ask Mom and Dad.