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Shopping for HIV Coverage A guide to paying for your care and treatment

Supplement to POZ magazine

What are my health care options? 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,” will expand insurance coverage for millions of people in the United States. Some of the provisions of the ACA went into effect after the law was passed in 2010, with even more to come in 2014. 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 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

Published by Smart + Strong, publishers of POZ and Copyright © 2012 CDM Publishing, LLC. All rights reserved. No part of this publication may be reproduced, stored or transmitted, in any form by any means, electronic, mechanical, photocopying, recording or otherwise, without the written permission of the publisher. Send feedback to POZ Focus c/o Smart + Strong, 462 Seventh Avenue, 19th Floor, New York, NY 10018. Tel: 212.242.2163;


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. Right now, some job-based plans won’t cover pre-existing health conditions (like HIV), or they impose a waiting period before coverage starts or charge higher premiums or out-ofpocket expenses. But 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.

Editor-in-Chief: Oriol R. Gutierrez Jr. Art Director: Mark Robinson Managing Editor: Jennifer Morton

Writer: Tim Murphy Copy Editor: Trenton Straube Publisher: Megan Strub

POZ Focus is an educational series on specific topics relevant to HIV. The editorial content is independently produced by Smart + Strong.


private plans will not be 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 PRIVATE INSURANCE Currently, private insurance plans can cost hundreds or even thousands of dollars a month. But one of the primary features of the ACA is the creation of state-run health insurance

Do you have health insurance through your job?


Employer-based insurance


exchanges. These exchanges will help individuals and small businesses purchase affordable and quality health insurance plans. If a state does not create an exchange, one may be available through the federal government. Starting in 2014, under the ACA,

Can you afford to pay for private health insurance?


State or federal health insurance exchanges



THROUGH MEDICARE AND/OR MEDICAID 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

Are you eligible for Medicaid or Medicare?






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, beginning 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.

What does the Affordable Care Act mean for me? The Affordable Care Act (ACA) was passed by Congress in 2010, and the majority of its provisions were upheld by the Supreme Court in 2012. With most of its big provisions going into effect in 2014, the ACA means that: ■

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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 on the map on the following page and call to see if you qualify. Even with new insurance coverage options through the ACA, Ryan White will still 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 PATIENT 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 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

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Insurers can’t deny you coverage because you have HIV or any other pre-existing condition, or based on your health status or gender. Insurers can’t cut off your coverage when you hit a certain cost ceiling. States will set up health “exchanges” where you can buy insurance if don’t already have it. (If the state chooses not to set up such an exchange, one will be available through the federal government.) If you make less than approximately $45,000 for an individual or $92,000 for a family of four, tax credits and subsidies can make insurance coverage more affordable for you. You no longer have to have an AIDS diagnosis to qualify for Medicaid. If you are covered through Medicare, you will pay half of what you’re paying now for brand-name drugs. Plus, you’ll no longer fall into Medicare’s drug-payment “doughnut hole” where you have to pay big bucks for your meds until you hit a certain cost point.

What about generic drugs? A generic version of a drug can be sold in the United States when the patent for the brand name expires. Generic drugs are approved by the Food and Drug Administration with the same strict standards as brand-name drugs and are generally the same quality. The primary difference is the price. So what does that mean for you? It depends on your current treatment regimen. If you are taking one of the newer drugs on the market, a generic version will not be available. If you are on an older regimen, you may be able to take a generic version of one or more of your drugs and save money on your co-pays. But you might have to take two or three different generic drugs rather than a combo version that’s still on patent. When deciding on a treatment regimen, you and your doctor need to pick the one that’s best for you. If generics are an option, talk to your doc about the pros and cons of switching. Odds are you won’t notice the difference between the two, but if you do notice any changes after switching to a generic, be sure to discuss them with your doctor immediately.

Can I advocate for better access to care and treatment? Check out these sites to learn more and find out how you can get involved: Treatment Access Expansion Project (TAEP) AIDS Treatment Action Coalition (ATAC) Treatment Action Group (TAG) Project Inform ADAP Advocacy Association (aaa+)


HOW WE DID IT Three individuals share how they get their health coverage David Bayer, 49, San Diego Store manager Diagnosed with HIV in 1990 “ADAP has always been a lifeline for me. I’ve depended on it for years, either for paying for my meds in full, or now just paying my co-pays on my job insurance. They’d cost me approximately $400 a month otherwise.”

Your state-by-state guide to coverage options

Joann Montes, 48, Chicago Consumer relations coordinator Diagnosed with HIV in 1999 “I use a pharma assistance program (PAP) for the co-pay of my current regimen. Through the years I’ve paid for my meds through ADAP, Medicaid and private insurance. The most nerve-wrecking moments were when I lost my job and had to apply for ADAP. The transition wasn’t smooth, and I had to rely on medication donations from a local AIDS group. At any rate, I am grateful I’ve had access to treatment this whole time.” Kenneth Winfrey, 40, Albuquerque Part-time clinical social worker Diagnosed with HIV in 1999 “My meds were initially covered by my employer’s insurance plan. After leaving that position due to my health, my COBRA plan was covered by ADAP. After that, I was placed into Medicaid/ Medicare under Social Security’s Working While Disabled Program. I’m grateful I’ve had coverage that provided for all my needs, and for the folks who helped me out when I wasn’t able to understand how my meds and care would be covered.”

Washington* 877.376.9316 $33,510 800.562.3022

Oregon* 971.673.0144 $33,510 503.945.5772

Idaho** 208.334.6527 $22,340 877.456.1233

Nevada* 775.684.3499 $44,680 800.992.0900

Utah* 801.538.6197 $27,925 Salt Lake City: 801.538.6155 Other areas: 800.662.9651

California* 888.311.7632 $50,000 916.445.4171

Arizona* 800.334.1540 $33,510 602.417.4000

Wyoming* / ** 307.777.5856 $38,300–$45,500 (varies by county) 307.777.7531

Colorado* 303.692.2716 $44,680 Denver: 303.866.3513 Other areas: 800.221.3943

New Mexico* 505.476.3618 $33,510 888.997.2583

Alaska* 907.263.2050 $41,910 907.465.3030

Hawaii* 808.733.9360 $51,440 808.586.4400

State-based exchange Federal-based exchange Federal-state partnership exchange Undecided


Montana* 406.444.4744 $36,861 800.362.8312

The map below shows the type of health-insurance exchange each state is planning to set up in order to meet the requirements of the Affordable Care Act. The map also provides: 1) State ADAP phone numbers; 2) ADAP gross eligibility limits for an individual household (unless otherwise noted); and 3) State Medicaid phone numbers (in bold).

Visit for links to ADAP and Medicaid office websites.

North Dakota* 701.328.2378 $33,510 (net income) 701.328.2321

South Dakota* 800.592.1861 $33,510 605.773.3165

Nebraska* 402.559.4673 $22,340 on disability; $27,925 if you’re working 800.642.6092

Vermont* 802.951.4005 $22,340 (net income) 800.250.8427 Minnesota* 800.657.3761 $33,510 800.657.3739

Oklahoma* 405.271.9444 x56616 $22,340 800.987.7767

Massachusetts* 800.228.2714 $55,850 800.841.2900

NH Wisconsin* 800.991.5532 $33,510 800.362.3002

Illinois* 800.825.3518 $33,510.00 800.447.4278

Missouri* 573.751.6439 $33,51 573.751.4815

Michigan* 888.826.6565 $50,265 517.373.3740


Indiana* / ** 866.588.4948 $33,510 800.403.0864

New York* 800.542.2437 MA $48,500 855.693.6765 CT Pennsylvania* 800.922.9384 $37,643 800.692.7462

Ohio* 800.777.4775 $33,510 800.324.8680


SC Georgia* 404.657.3127 $33,510 404.656.4507

Louisiana*/** 504.568.7474 $33,510 888.342.6207

Mississippi 601.362.4879 $44,680 (CD4 cell count must be below 500) 800.421.2408


Rhode Island 401.222.4610 $44,680 401.462.5300 Connecticut* 800.233.2503 $44,680 (net income) 877.284.8759

Delaware* 302.744.1050 $55,850 800.372.2022

West Virginia* $36,303 800.642.8589 South Carolina* 800.856.9954 $33,510 800.549.0820



New Jersey* 609.588.7038 $55,850 800.356.1561

North Carolina* 877.466.2232 $33,510 800.662.7030

Tennessee* 800.525.2437 $33,510 800.342.3145



Virginia* 855.362.0658 $44,680 804.786.6145


Alabama* 866.574.9964 $27,925 800.362.1504



Kentucky* 866.510.0005 $33,510 800.635.2570

Arkansas* 800.462.0599 $22,340 800.457.4454

Texas* 800.255.1090 $22,340 800.252.8263

Maine* 207.287.3747 $55,850 207.287.3707


Iowa* 515.281.0926 $22,340 (plus an extra $500 per month if you’re employed) 515.256.4600

Kansas* 785.368.6567 $33,510 888.369.4777

New Hampshire* 603.271.4502 $33,510 (CD4 cell count must be below 500) 603.271.4344

Maryland* 800.205.6308 $55,850 877.463.3464 Washington D.C.* 202.671.4900 $54,150 877.672.2174

Florida* / ** 850.245.4335 $44,680 888.419.3456

* State may cover some or all of your private or job-related insurance premiums and/or co-pays. ** This state’s ADAP had a waiting list or capped enrollment as of October 2012. But don’t let that stop you from calling for updates or more info. Data current as of November 2012. PAYING FOR CARE AND TREATMENT POZ FOCUS 5


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POZ Shopping for HIV Coverage Focus 2012  
POZ Shopping for HIV Coverage Focus 2012  

A guide to paying for your care and treatment; a supplement to POZ magazine