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Selecting an Obamacare Plan When You're Starting Treatment for HIV

October 30, 2014

The Patient Protection & Affordable Care Act (PPACA, or ACA), generally known as "Obamacare," has some clear benefits for people living with HIV. You can no longer be denied coverage because of a pre-existing condition and premiums can't be based on sex. If you have kids, they can be covered by your policy until age 26, and there's no lifetime cap on covered costs. Sounds good, right? But if you are looking at ACA exchange plans as you get ready to start HIV treatment, here are some suggestions to help find one that will best meet your specific needs.

Talk to a Human

The whole process of buying insurance can be handled on the Internet. But for your own protection, it may be best to consult a specially trained "navigator." Prepare yourself for the consultation by:

  • Gathering documentation -- photo ID, proof of address, income verification (tax return or W-2), proof of prior insurance, a complete and current list of all medications you take, and a list of all your medical providers' names. Decide ahead of time what you are willing to compromise on, if there's not one plan that has everything you want: Are you willing to change doctors, or go from taking one pill once a day to several pills several times a day?
  • Being realistic about what you can afford to pay without affecting other factors that influence your health, such as housing, transportation, food or childcare.
  • Taping the conversation if you don't take good notes. However, remember to tell the navigator you're taping it!
  • Remembering to get the name of the person you talk to and note the date and time the conversation starts and ends, as well as any time you spent on hold.
  • Being prepared to ask for explanations if you don't understand something. Repeat the answers you're given, so you both know you got them right.
  • Waiting to sign anything until you feel 100% confident that you know how much you're paying, what's covered, how much your out-of-pocket (OOP) costs will be, and what doctors are in your network.

Though it's good to go into this optimistic, and with an open mind, you may find that answers to your questions will differ from person to person. It's best to have proof of everything you've been told.

Will it Provide for Your Providers?

If you already have a doctor you trust as your primary care physician (PCP):

  • Ask specifically if that doctor is in the network. If not, ask if he or she is included in any of the networks offered, and if so, how much that plan would cost.
  • If there is no network to which your PCP belongs, you must choose between keeping him/her as your PCP as an out-of-network (OON) provider, or trying a network provider. Ask about the cost difference.
  • If choosing from the network, ask if any of the PCPs listed are also HIV specialists.
  • Make sure you can change PCPs if you don't like the one you've chosen.

Will They Cover the Drugs You Need?

You may have read about people with HIV facing higher costs for their HIV treatment in the new plans. This is a point where the more information you have, the better off you'll be.

  • Keep a current list of your drugs (with dosages) with you whenever you're going to talk about your insurance, as well as a list of the drugs you are considering taking.
  • Ask specifically what the copay for your drugs will be. If there's no answer, ask your pharmacist.
  • If you're considering a single tablet regimen (like Atripla, Complera, etc.) or a fixed dose combination (Combivir, Kaletra, etc.), make sure it will be covered in that form -- as more generics appear, some plans might require you to take each drug in a separate pill.

Understanding the True Cost of a Plan

Many people make the mistake of only looking at the cost of a plan's premium. Many people will qualify to receive either subsidies or tax credits to help them pay their premiums. But in addition to the premium, you must also pay OOP costs before your health insurance starts to pay 100% for the covered essential health benefits. Until that limit is met, you'll pay from 10 to 40% of the total cost. The maximum OOP cost limit for an individual in 2015 can be no more than $6,600 (up from $6350 in 2014) and $13,200 for a family plan. This limit includes:

  • Deductibles.
  • Coinsurance. This is the percentage of total cost you must pay. For bronze plans you pay 40%, for silver 30%, for gold 20%, and for platinum 10%.
  • Copays for provider visits.
  • Any other expense you pay that's considered a qualified medical expense for the essential health benefits, which can include:

    • Outpatient services (care you get without being admitted to a hospital).
    • Emergency services.
    • Hospitalization (such as surgery).
    • Pregnancy, maternity, and newborn care.
    • Mental health and substance abuse services, including behavioral counseling and psychotherapy.
    • Prescription drugs.
    • Rehabilitative services and devices (to help people to gain or regain mental and physical skills).
    • Laboratory services.
    • Preventive/wellness services and chronic disease management.
    • Pediatric care.

This limit does not include the following items. That means that if you pay them, it does not contribute toward the OOP total and does not get you closer to reaching the maximum cost limit:

  • Premiums.
  • Amounts for non-network providers and other OON cost-sharing.
  • Spending for nonessential health benefits. This can differ according to company and plan, but can include services like chiropractic care, massage therapy, imaging (X-rays, ultrasounds, etc., though these are sometimes included in outpatient services), nutritional counseling, or podiatric services.

So here is how you can estimate the true maximum cost of your insurance:

  • Add up your yearly premium cost (pre-subsidy or tax credit), the OOP maximum and what you think you may have to spend on additional costs that do not count toward the OOP total (such as services from OON providers and "non-essential" health benefits). A navigator may be able to help you estimate these costs.
  • Then, subtract any subsidy or tax credit you'll receive and you'll have the true estimated yearly cost of your health coverage.

The Bottom Line: Do the Legwork to Get the Plan You Need

Unfortunately, there is no simple way to be sure that your health insurance guarantees to provide the actual health care you need when you are starting treatment for HIV. Just like with HIV itself, you're a step ahead of the game if you go into it armed with knowledge and by taking advantage of the resources that can help you in your quest. has many resources for people with HIV and providers about getting a plan to meet your needs.

Sue Saltmarsh has worked in the HIV/AIDS field for over 20 years, the first 10 as an herbalist and energy therapist at Project Vida, the last six as a writer and copy editor for Positively Aware magazine. She is now a freelance writer and editor and is also able to devote more time to her passion as founder and director of the Drive for Universal Healthcare (DUH).

Copyright © 2014 Remedy Health Media, LLC. All rights reserved.

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This article was provided by TheBody.
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