Supplement to POZ magazine

Shopping for HIV CoverageA guide to paying for your care and treatment

FOCUS

PAYING FOR CARE AND TREATMENT POZ FOCUS 1

Published by Smart + Strong, publishers of POZ and POZ.com.

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

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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.

ILLUSTRATIONS BY PETER HOEY

The soaring cost of health care in the United States can make securing cover-age for yourself or your family a daunt-ing 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 resi-dence, income, employment and health status, age and citizenship. Thankfully, the Affordable Care Act (ACA), other-wise 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 insur-ance coverage to get your specific needs covered. Many local AIDS ser-vice 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 in-surance. Many small businesses also offer insurance to their employees be-cause doing so means they qualify for tax credits. Whether you already have a job with health insurance or are con-sidering taking a new one, it’s impor-tant to know that employers who offer health care can’t discriminate against

employees based on their health status.You may need to ask whoever han-

dles 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 condi-tions (like HIV), or they impose a waiting period before coverage starts or charge higher premiums or out-of-pocket expenses. But as of 2014, the ACA will make all health plans cover pre-existing conditions immediately.

In many states, AIDS Drug Assis-tance Programs (ADAP) will continue to help you pay premiums and co-pays on your job-based insurance.

What are my health care options?

2 POZ FOCUS PAYING FOR CARE AND TREATMENT

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

exchanges. These exchanges will help individuals and small businesses pur-chase affordable and quality health insurance plans. If a state does not create an exchange, one may be avail-able through the federal government.

Starting in 2014, under the ACA,

private plans will not be allowed to block you out or charge you more be-cause of HIV or any other pre-existing condition. Plus, if you make between $11,170 and $44,680 a year as an indi-vidual, or $23,000 to $92,200 as a family of four, you’ll be able to get tax subsi-dies 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 MEDICARE

AND/OR MEDICAID

A little over half of all Americans with HIV get their meds and health care through these federal programs. Cur-rently you can qualify for Medicaid if you have a low income and are part of a “categorically eligible” group (children, parents with dependent children, preg-nant women, and people with disabili-ties). 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 perma-nently disabled. That won’t change with the ACA. But one change to Medi-care that’s already in effect because of the ACA is that you pay only half of

Employer-based insurance

State or federal health insurance

exchanges

Medicaid Medicare

ADAP or PAPsNO NO NO

YES YES YES

Do you have health insurance

through your job?

Can you afford to pay for

private health insurance?

Are you eligible for Medicaid or

Medicare?

PAYING FOR CARE AND TREATMENT POZ FOCUS 3

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 differ-

ence between the two, but if you do notice any changes after switching to

a generic, be sure to discuss them with your doctor immediately.

Check out these sites to learn more and find out how you can get involved:

Treatment Access Expansion Project (TAEP) taepusa.org

AIDS Treatment Action Coalition (ATAC) atac-usa.org

Treatment Action Group (TAG) treatmentactiongroup.org

Project Inform projectinform.org

ADAP Advocacy Association (aaa+) adapadvocacyassociation.org

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.

THROUGH THE RYAN WHITE CARE ACT AND THE AIDS DRUG ASSISTANCE PROGRAM (ADAP)The Ryan White CARE Act is the larg-est federally funded program for people with HIV. It provides care and support services to people who don’t have in-surance 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 de-pends 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 pharmaceu-tical companies have banded together to offer free or heavily discounted drugs to help people with low-incomes who do not qualify for any other insur-ance 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 pro-grams, visit poz.com/drugassistance.

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:

■ 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?

What does the Affordable Care Act mean for me?

Can I advocate for better access to care and treatment?

4 POZ FOCUS PAYING FOR CARE AND TREATMENT

David Bayer, 49, San DiegoStore managerDiagnosed 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 approxi-mately $400 a month otherwise.”

Joann Montes, 48, ChicagoConsumer relations coordinatorDiagnosed with HIV in 1999

“I use a phar-ma assistance program (PAP) for the co-pay of my current regi-men. Through the years I’ve paid for my meds through

ADAP, Medicaid and private insur-ance. 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, AlbuquerquePart-time clinical social workerDiagnosed 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.”

Your state-by-state guide to coverage options

Washington*877.376.9316$33,510

800.562.3022

Oregon*971.673.0144$33,510

503.945.5772

California*888.311.7632$50,000

916.445.4171

Nevada*775.684.3499 $44,680

800.992.0900

Idaho**208.334.6527$22,340

877.456.1233

Montana*406.444.4744 $36,861

800.362.8312

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

307.777.7531

Utah*801.538.6197$27,925

Salt Lake City: 801.538.6155Other areas: 800.662.9651

Colorado*303.692.2716 $44,680

Denver: 303.866.3513Other areas: 800.221.3943

Arizona*800.334.1540 $33,510

602.417.4000

New Mexico*505.476.3618$33,510

888.997.2583

HOW WE DID IT

Three individuals share how

they get their health coverage

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

PAYING FOR CARE AND TREATMENT POZ FOCUS 5

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 poz.com/eligibilitymap for links to ADAP and Medicaid offi ce websites.

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

South Dakota*800.592.1861 $33,510605.773.3165

Nebraska*402.559.4673 $22,340 on disability; $27,925 if you’re working800.642.6092

Kansas*785.368.6567$33,510 888.369.4777

Oklahoma*405.271.9444 x56616 $22,340800.987.7767

Texas*800.255.1090$22,340800.252.8263

Minnesota*800.657.3761$33,510800.657.3739

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

Missouri*573.751.6439 $33,51573.751.4815

Arkansas*800.462.0599$22,340800.457.4454

Louisiana*/**504.568.7474$33,510888.342.6207

Mississippi601.362.4879$44,680 (CD4 cell count must be below 500)800.421.2408

Wisconsin*800.991.5532$33,510 800.362.3002

Illinois*800.825.3518$33,510.00800.447.4278

Indiana* / **866.588.4948 $33,510800.403.0864

Ohio*800.777.4775$33,510800.324.8680

Michigan*888.826.6565$50,265 517.373.3740

New York*800.542.2437 $48,500855.693.6765

Vermont*802.951.4005 $22,340 (net income)800.250.8427

Massachusetts*800.228.2714$55,850800.841.2900

Rhode Island 401.222.4610$44,680401.462.5300

Connecticut*800.233.2503$44,680 (net income)877.284.8759

New Jersey*609.588.7038$55,850800.356.1561

Maryland*800.205.6308$55,850877.463.3464

Delaware*302.744.1050$55,850800.372.2022

Washington D.C.*202.671.4900$54,150877.672.2174

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

Pennsylvania*800.922.9384$37,643800.692.7462

Virginia* 855.362.0658 $44,680804.786.6145

Kentucky* 866.510.0005 $33,510 800.635.2570

North Carolina*877.466.2232$33,510800.662.7030

Tennessee*800.525.2437 $33,510800.342.3145

Alabama*866.574.9964$27,925800.362.1504

Georgia*404.657.3127$33,510404.656.4507

South Carolina*800.856.9954$33,510800.549.0820

Florida* / **850.245.4335$44,680888.419.3456

West Virginia*$36,303800.642.8589

Maine* 207.287.3747 $55,850207.287.3707

IN

LA

MS

FL

SC

WV

MA

VTNH

CT

NJ

DEMD

DC

RI

* 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.

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