The soaring cost of health care in the United States can make securing coverage for yourself or your family a daunting task. But if you’re HIV positive, then figuring out how to pay for your care and treatment and how to navigate the country’s state-by-state patchwork of health care options can be downright overwhelming. Your eligibility for coverage depends on your state of residence, income, employment and health status, age and citizenship. Thankfully, the Affordable Care Act (ACA), otherwise known as “ObamaCare,” has expanded insurance coverage for millions of people in the United States.
Since there are so many ways to get health coverage, it’s important to first work with your doctor or health care professional to decide on the right treatment regimen for you. There are many ways to supplement your insurance coverage to get your specific needs covered. Many local AIDS service organizations can even help you navigate your options. You can find one near you at directory.poz.com.
Here’s a breakdown of how you can get your HIV care and medication:
Through Your Job
Employers with 50 or more employees are required by law to offer health insurance. Many small businesses also offer insurance to their employees because doing so means they qualify for tax credits. Whether you already have a job with health insurance or are considering taking a new one, it’s important to know that employers who offer health care can’t discriminate against employees based on their health status.
You may need to ask whoever handles the health plan at your job—or your prospective job—for the details of your plan, so that you can find out if it covers the drugs and care you need as well as how much you’ll have to pay out-of-pocket. But it’s up to you whether you want to come right out and disclose that you have HIV.
In the past some job-based plans wouldn’t cover pre-existing health conditions (like HIV), or they would impose a waiting period before coverage starts or charge higher premiums or out-of-pocket expenses. As of 2014, the ACA will make all health plans cover pre-existing conditions immediately.
In many states, AIDS Drug Assistance Programs (ADAP) will continue to help you pay premiums and co-pays on your job-based insurance.
Through Private Insurance
Private insurance plans used to be cost prohibitive. But one of the primary features of the ACA is the creation of state-run health insurance exchanges. These exchanges help individuals and small businesses purchase affordable and quality health insurance plans. If a state does not create an exchange, the federal government may make one available.
Beginning in 2014, under the ACA, private plans are not allowed to block you out or charge you more because of HIV or any other pre-existing condition. Plus, if you make between $11,170 and $44,680 a year as an individual, or $23,000 to $92,200 as a family of four, you’ll be able to get tax subsidies to help pay premiums on your plan. (If you’re an immigrant who is not eligible for Medicaid because you haven’t lived in the United States for more than five years, you may still be eligible for these subsidies.) And like employer-based insurance, in some states, ADAP may be able to help with your premiums and co-pays.
Through Medicaid and/or Medicare
A little over half of all Americans with HIV get their meds and health care through these federal programs. Currently you can qualify for Medicaid if you have a low income and are part of a “categorically eligible” group (children, parents with dependent children, pregnant women, and people with disabilities). In 2014, states have the option of allowing you to be eligible for Medicaid without being disabled (or part of any other eligible group) if your income is 133 percent below the federal poverty level. (You must make less than $14,860 a year if you’re an individual, or $30,650 a year if you’re a family of four.) Contact your state’s Medicaid office to find out if this option is available to you.
You can qualify for Medicare if you are age 65 or older or if you are permanently disabled. That won’t change with the ACA. But one change to Medicare that’s already in effect because of the ACA is that you pay only half of what you used to pay for brand-name prescription drugs. And if ADAP pays for your medications, those payments now count toward bringing you up to the Medicare range where nearly all your costs are covered.
In addition, starting in 2014, the infamous Medicare “doughnut hole,” in which you have to pay all of your drug costs until you reach a certain amount, will be gradually eliminated.
Through the Ryan White CARE Act and the AIDS Drug Assistance Program (ADAP)
The Ryan White CARE Act is the largest federally funded program for people with HIV. It provides care and support services to people who don’t have insurance or don’t have enough coverage through their other plans. Ryan White also provides funding for ADAP. About a third of Americans in care for HIV get their meds through this federal-state partnership. But income requirements, plus exactly what ADAP covers, vary greatly by state. Find your state’s ADAP info here and call to see if you qualify.
Even with new insurance coverage options through the ACA, Ryan White continues to play a huge role to help with gaps in coverage and affordability. But the funding for this program depends on Congress, so it’s important to advocate for its reauthorization. In recent years, some states have had to create waiting lists for ADAPs.
Through Patience Assistance Programs (PAPs)
Finally, as a last resort, the pharmaceutical companies have banded together to offer free or heavily discounted drugs to help people with low-incomes who do not qualify for any other insurance or assistance programs. About 30,000 Americans with HIV get their meds this way. You and your doctor can find the application form you need at hab.hrsa.gov/patientassistance.
In addition to PAPs, some pharma companies offer co-pay assistance for their drugs, including non-HIV drugs. For info on PAPs and co-pay programs, visit poz.com/drugassistance.
Last Revised: February 14, 2016