Public Benefits and HIV

Health Benefits

1. AIDS Drug Assistance Program (ADAP)

ADAP provides US Food and Drug Administration (FDA)-approved HIV/AIDS related prescription medications for uninsured or underinsured individuals. You may have no health insurance, be on Medicare, or have private insurance with co-pays for your medication. Each state has its own requirements and list of covered HIV-related drugs, so requirements and medications provided vary by state. All states want proof that you are HIV+, but not all require that you be at a certain stage of the disease. States also vary in whether they look at income only or income plus assets in evaluating qualification for ADAP.

Many states have been forced to implement waiting lists, eligibility restrictions, spending limits, and other methods to control costs. As of March 14, 2013, there were 65 people on ADAP waiting lists in three states. If you are unable to access medications through your state's ADAP program, you may be able to access medications through a State Pharmaceutical Assistance Program (SPAP). Contact your county or an AIDS service organization for more information.

2. Medicaid

Currently, Medicaid covers various categories of low-income adults and children. Because it is an entitlement program, everyone who meets the guidelines can get services. Services include mandatory benefits and states can also choose to offer a broad range of optional benefits, so coverage depends on the state. Insurance through Medicaid may come automatically with TANF or SSI. Some counties also provide Medicaid if you have limited income or resources. Starting in 2014, you no longer have to be disabled or fall into another qualifying category to be eligible for Medicaid. The program will be available to most people who have income up to 133% of the federal poverty level (in 2013, this is $15,282 for an individual and $31,322 for a family of four). Contact your county or an AIDS service organization for more information.

3. Medicare

Medicare covers people over the age of 65 and those who are disabled (with a work history) or blind. You automatically qualify for Medicare after 24 months of SSDI payments. Medicare is divided into several different parts, which have different application procedures; all except Part A are optional. These consist of:

• Part A (limited hospital care, skilled nursing, some home care, and hospices)
• Part B (health care providers, outpatient hospital services, and other medical care)
• Part C ("Medicare Advantage," or access to managed care plans)
• Part D (outpatient prescription drugs)

Co-payments, deductibles, and other financial aspects vary by plan. Up until now, many people living with HIV who accessed medications through Medicare Part D fell into the "doughnut hole" where they had to pay 100% of the costs of their drugs until they paid $4,550 (in true-out-of-pocket costs, or "TrOOP") and moved into catastrophic coverage. The good news is, if you hit the doughnut hole in 2013, you will receive a 52.5 percent discount on brand name drugs, and a 21 percent discount on generic drugs. These changes are the result of the Affordable Care Act, which will shrink the doughnut hole until it closes in 2020.

In addition, starting in January 2011, you can now use ADAP expenses to count towards your TrOOP, which will make it easier to get through the Medicare Part D "doughnut hole" faster. You may also want to see if you can get Medicaid to pay for your Medicare premiums and costs that Medicare does not cover. If you are not able to get Medicaid, you may want to see if you can get ADAP.

4. Other Programs

Many states run Ryan White clinics or other programs to help people with no other access to care. These vary widely by state, and you should contact your local ASO to see what programs and clinics are available in your area.

Taking Care of Yourself

If you are unable to work due to physical, mental, or mood-related symptoms of HIV and/or other conditions, you may qualify for benefits.

• Be persistent with your applications, appeal any denials, and try to get an advocate or attorney to represent you through a local Legal Aid society, an AIDS service organization, or a private attorney's office
• See your medical provider as often as possible for the best medical treatment as well as support with your benefits claims
• Report all symptoms to your medical provider and keep documentation of symptoms, medications, and treatment to help when you file a claim
• Fight for what you deserve -- the most income and health insurance that you and/or your family are allowed

Much of the above information was supplied by Positive Resource Center (www.positiveresource.org) and from materials prepared by Treatment Access Expansion Project (www.taepusa.org).