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Cost of labwork, insurance premium and copay assistance
Mar 21, 2014

Hello, I'm in the precarious position of being just over the income line for no longer qualifying for Ryan White/ADAP assistance (200% of the federal poverty level.) So, as he deadline for Obamacare looms ahead on March 31, I need to find a plan that I can afford (this is seemingly impossible.) My first question is: how much does the lab/blood work cost for a regular checkup visit? This is out of pocket till the deductible is reached on all plans from what I understand. I suspect it is very expensive and I would want to prepare for having to pay for something like that every 6 months (IF the Doctor would agree to limit checkups to every 6 months.) The prescriptions usually have just a copay (around $50 per med on most plans, which also hurts.) I live in Texas and they tell me Ryan White cannot help with premiums/copays either due to an ongoing legal battle. So I'm looking at $250-300 a month in premiums and copays plus a deductible in the thousands on a self employed income of 24,000 a year. Not seeing how this is doable unless I find some sort of assistance. Are there any alternatives or solutions? Nobody seems to really know much at this point how this is all going to work. The people at the clinic look at me like they feel really bad for me. (side question: Wouldn't it be a better more efficient use of funds at Ryan White to help low income people afford regular insurance??) Thanks for any advice or pointing me toward people who can help work this out.

Response from Mr. Chambers

That is a rock and a hard place, or, more accurately, Texas and HIV. Although Texas does have an AIDS Drug Assistance Program (ADAP), its income limits are lower than most states. Also, they haven't adopted a premium assistance program as many states have. And to top it off, you aren't eligible for regular Medicaid and Texas does not offer Medical Necessity Medicaid which would let you in, but with a deductible.

Go back to the health exchange site. I'm pretty sure Texas didn't create their own and uses the federal site: Since you are just above 200% Federal Poverty Lever (FPL)you should qualify for considerable federal assistance on premiums. Also, as long as you are below 250% FPL there will be some help with deductibles and copays.

The biggest problem people with HIV are having now with this program is a lack of information on which plans contract with which doctors and what prescriptions are on each plan's formulary, so it will take some research on your part to dig it out.

If possible, use a certified enroller or navigator who is also familiar with HIV and its programs. Many AIDS Service Organizations have had some of their staff get trained, so start the search there.

When you search for plans remember they do not use your gross income, but instead, your net profit in determining what financial assistance you are eligible for. They use the Modified Adjusted Gross Income (MAGI). You can get the definition of that figure at the IRS website.

As far as costs of medical procedures such as lab tests, etc. the prices vary far too much to give you an estimate you could rely on. Talking about the cost of medical care before you undergo it is pretty much unheard of in this country. Hopefully, your doctor may be able to give you an idea of the cost of tests from the lab he/she uses.

While there is help getting insurance and paying for services for low income people, you may be at one of those points where there is some help, but not enough to meet your needs.

Don't give up. Good luck, Jacques

Do I have to pay?
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