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am I really going to pay 25% of my HIV meds with ACA?
Nov 12, 2013

am I really going to pay 25% of my HIV meds with ACA?

Response from Mr. Chambers

The short answer is "No," but this gives me a great excuse to expand on the law and how it can help persons living with HIV/AIDS.

First there is no set percentage that ACA (the Affordable Care Act or Obamacare) requires the insurance company to pay. It does limit the plans provided through the state and federal health insurance exchanges to five different types of plans:

Platinum plans are designed to cover 90% of the "average annual cost"

Gold plans will cover 80% of the average annual cost.

Silver plans will cover 70% of the average annual cost.

Bronze plans will cover 60% of the average annual cost.

Catastrophic plans are Bronze plans with a high deductible and are designed for the healthy, young person.

In addition, all plans must limit how much you pay out-of-pocket each year to no more than $6,350 per person or $12,700 per family. They must also cover a substantial number of preventive procedures in full without any deductible.

Note that those averages are just that. Each plan may have deductibles (amounts to be paid before the insurance company pays), copays (a dollar amount charged at the point of service), and/or coinsurance (percentage of the charge, with the insurance company paying the remainder).

Medications tend to have copays, where the insured person pays a set fee for each medication. The amount depends on whether it is brand name or generic, preferred or non-preferred. Each insurance company may arrange what they charge however they want provided the overall percentage falls within the plan's average.

So the amount you will pay as the insured person will vary dramatically. Of course, most HIV medications will be brand name and, hopefully, many will be preferred medications on the plan's formulary.

I should also mention that persons with lower income will get assistance with paying their insurance premiums. Plus persons with low incomes who select the Silver Plan will also have assistance paying their deductibles, copays, and coinsurance as well as a reduced out-of-pocket limit depending on how low their income is.

There are several things a person with HIV should be aware of when finding the right health plan under ACA.

First find out if your state has an ADAP/HIV program that provides assistance with the portion of the premiums you are asked to pay.

Second, make sure you join your state's AIDS Drug Assistance Program (ADAP) if you are eligible.

Third, because these plans use "network" or contracting providers, you want to find a plan that includes your doctor. Your doctor's office should be able to help with that.

Finally, check the prospective plan's formulary. If you are on ADAP, make sure it covers your medications that are not on the ADAP formulary. If not, make sure it provides coverage for all your medications.

I realize that there are problems with the federal website and not all of this information is going to be readily available, although some state exchanges are doing better. Either way, I encourage you to get some assistance before settling on a plan.

First start at the federal health exchange: www.healthcare.gov. If your state has its own exchange, you will be referred to that site. Shop around and look at some of the plans. See what is available on line and get an idea of the range of plans.

Have an idea of what programs your state's AIDs programs offer to assist you.

Certified Enrollers are being trained nationwide to assist you with questions. Because of the special needs and assistance available to persons with HIV, many AIDS Service Organizations are getting members of their staff certified. If available, use one of these to get in the right plan.

I realize this is complicated, but it is the first opportunity for persons who desperately need insurance coverage to get it without penalties for their medical condition. It will get better.

You won't remember, but I do. Medicare was a mess to get up and running in 1965, yet today it and Social Security are the most popular government-run programs.

Don't forget, you need to enroll in a plan by December 15 for your coverage to be effective January 1, 2014.

Good luck, Jacques



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