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Getting and Keeping Insurance When You Are HIV Positive

By Mark Scherzer, Esq.

July 2003

Table of Contents

Why should I have insurance?

Health insurance can be the best way to protect your health and your pocketbook if you have HIV. Health insurance pays for you to be treated by doctors and hospitals and to get prescription drugs you could not pay for yourself.

Can I get health insurance?

Yes, you can. Having HIV does not prevent you from getting health insurance. There are many different ways to get coverage. There are also laws that protect your rights.

One of the best ways to get health insurance is to go to work for an employer who provides it. No matter where you live or work in the U.S., group health plans have to treat all similar employees the same. You cannot be rejected and cannot be charged a higher premium because you have HIV, or are a woman, or are older.

If you do not work, or your employer does not offer health coverage, then you may have a harder time. You should first check if you qualify for any public health insurance programs.

In most states the Medicaid program is for people with very little income or assets. Some states have added programs for people with a little more money, especially people who have a child in the Child Health Plus program (a program for children with family incomes too high for Medicaid).

Also, all states have AIDS Drug Assistance Programs ("ADAP") that can help people with limited incomes get AIDS drugs. The Legal Services offices in most states can tell you how to enroll in these public programs.

If you cannot qualify for a public program, you may be able to buy individual insurance. In some states, all insurers must offer individual insurance to any resident who can pay for it. This is called open enrollment. In other states, Blue Cross sells individual plans.

In most states, however, insurers can turn down an HIV+ person, and if you live in that kind of state you will have to get your coverage through a "high-risk pool," where premiums may be more expensive than for regular insurance policies.

How do I know what my insurance covers?

If you buy individual coverage, the insurance company should give you an insurance policy. Make sure to read the policy. If you don't have it, ask the company for a duplicate.

If you get coverage from your employer, you must be given a "summary plan description" (SPD) that has the rules of the plan in it. The SPD will tell you how to appeal if your claims are denied or services are not authorized. The SPD should also tell you who makes decisions and how you can get more information.

Can my insurance be canceled once I have it?

If you buy insurance on your own, it cannot be canceled unless you fail to pay your premium, you commit fraud on the insurer, or the insurer drops all the individual policies like yours in your state. Also, if you are in a managed care plan, your coverage may be canceled if you move out of the plan's service area.

If you have insurance through a group where you work, your coverage can be canceled if you stop working, or do not work enough hours to be eligible. If you have your coverage through your husband, it can also be canceled if you get divorced or your husband dies.

What can I do when my coverage ends?

If you lose your individual coverage because you failed to pay for it, there will sometimes be a grace period when you can pay and coverage will be reinstated. But if you miss this grace period, you may have to try to find another policy instead.

If you lose your group coverage and the employer has 20 or more employees, there are rules in a federal law known as "COBRA" that let you pay the employer to stay as part of the group for a limited time.

If you want to keep your coverage through COBRA, make sure to get the election form your employer, sign and return it in 60 days, and pay the full amount of the premium required. How long you can be on COBRA depends on circumstances:

Other important points about COBRA:

What happens if I change groups?

Some plans will not pay for pre-existing conditions for the first 12 months. A pre-existing condition is a medical condition that was treated or that you consulted with someone about in the three months before your coverage began.

Luckily, there are rules, known as "portability" rules, to protect you when you switch plans:

Make sure you know your rights and understand the rules for insurance in your state so that you can get the best coverage.




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