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Which ACA plan is best for the HIVer?
Mar 3, 2014

I am a healthy HIV+ individual (62) who needs to sign up for one of the ACA plans. I need insurance that will cover my medications (truvada, Isentress), regular blood work and the occasional malady (flu, etc.). I've checked the various plans on our state (Hawaii) health exchange website, but I find them confusing at beast undecipherable at worst. My questions are, will all the various plans (bronze, silver, gold, platinum) cover the HIV medications (which, at around $24,000/year, is the main cost), and considering I don't need much medical care other than the meds and blood work, which plan would be best for me? (I'm not eligible for any subsidies, by the way.) I realize it is difficult to make recommendations without knowing more specifics, but any kind of educated guess would be helpful for my planning. Thank you so much for your help with this!

Response from Mr. Chambers

There is no one particular plan or level that is good for everyone with HIV/AIDS. There are many factors that go into making a decision on what is best for you.

You mentioned you are not eligible for any subsidies. Coverage assistance is only for single individuals with annual earnings below $28,725. Premium assistance ends for a persons with the annual earnings exceed $45,960. Those are the main federal subsidies and assistance.

Depending on what state you live in, you may get prescription assistance from the AIDS Drug Assistance Program (ADAP) as well as additional assistance with premiums if your annual earnings are less than $50,000 through government programs for people with HIV/AIDS.

Assuming you are not eligible for any of those named above, it boils down to choosing between reduced benefits for lower monthly premium and broader benefits with higher monthly premiums. A Platinum Plan will pay about 90% of your medical bills, but the premiums for a Platinum Plan are the highest of the four levels of coverage. It becomes a matter of comparing your premium outlay with your out-of-pocket expenses of the plan.

Once you have decided on what level of coverage (Bronze, Silver, Gold, or Platinum) is best for you, then it is a matter of deciding which Plan at that level to buy.

Depending on the website and literature in your state, you may have some difficulty exploring further, but there are two important details you need to learn. First, is the doctor or doctors you see regularly (and want to continue with) members of the plan's network. Any plan will cost you much more out-of-pocket if you use non-network physicians and hospitals.

Next, you need to find out if your medications are on the plan's formulary since each plan decides what medications to cover within some guidelines. This may necessitate contacting the carrier or using the assistance of a plan navigator or enroller who can help you get the answers you need to decide.

This is especially important as there are some legal actions being filed claiming that some carriers in some states intentionally "juggled" their drug formulary to discourage people with HIV/AIDS from enrolling in their plan.

Good luck, Jacques



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