Things to Know About Paying For
Affordability is important for your HIV regimen both now and in the future because that regimen is going to keep you alive and well indefinitely if you stick with it (adhere to it) and being able to buy it on time, every time, comes into play with adherence.
There are quite a few assistance options and we've dedicated this 17th Annual Financial Guide to most of those options currently available. The biggest portion of this guide is dedicated to the AIDS Drug Assistance Programs (ADAP) for each state.
The ADAP for individual states offers assistance to many people who are HIV-positive and have nowhere else to turn for life-saving treatment. ADAP is funded federally but that doesn't mean that it is equal for all states. On the contrary, it varies widely in some states so our listing here is important for you to look over to see if what you need is covered and if you qualify in your state - or a state you might be moving to in the near future.
We always recommend as the first step you should take in the process is to visit an AIDS Service Organization (ASO) in your area or call one in an area you’re moving to. There is a listing of ASOs across the country online at our website: www.hivpositivemagazine.com/aso.html. Or, your state HIV/AIDS hotline should be able to give you the name and address of an ASO near you. You can also find a listing of state hotlines by going to our website: www.hivpositivemagazine.com/hotlines.html
An ASO may assign you a "case manager." (Some ASOs assign all their clients a case manager.) If you're coping well on your own but need a little help with specific problems, you may work with a Benefits Counselor. They know how to fill out the forms. They know who to call. They know the difference between how a program is supposed to work and how it really works. And, these days, most are as up on the ACA, health care marketplaces and exchanges as any ACA insurance advisor.
You can also check in with an ACA insurance advisor, although it seems they are becoming scarce. They are paid by the insurance companies and should be aware of all the marketplace options available for you. Make sure you are up-front with them about your HIV status, otherwise, you could get into an insurance plan that will be very expensive for you. Https://localhelp.healthcare.gov/ might be of assistance in finding a nearby advisor for you. Or, if you're feeling energetic, you can look at the health insurance exchanges online yourself and find one that works best for you.
The more you know personally, the more empowered you’ll be to take charge of your own financial and insurance coverage situation.
The Affordable Care Act (ACA-or-Obamacare) has made available insurance coverage for millions of uninsured Americans. Before the ACA was signed into law, insurance companies could deny coverage to someone on the basis of pre-existing conditions like HIV. After being challenged, the Supreme Court’s decision to uphold the “Individual Mandate” portion of the ACA was a victory for people living with HIV who had previously been shut out of the health insurance market.
These changes to the health care system and insurance can be complicated and vary state-by-state. As an example, health insurance companies place their coverage, deductibles and prescription plans on “tiers.” The patient’s cost depends on the tier in which the drug has been placed. The tier structures of HIV drugs then, are very important as to the affordability of the plan and drug. In 2014, a study commissioned by PhRMA (Pharmaceutical Research and Manufacturers of America) and carried out by Avalere Health surveyed 123 insurance plan formularies (drugs covered) and found that in 26%-to-39% of the plans (varying by four drug categories) HIV drugs were amongst the highest tier co-pay at 30%-to-40%. The findings basically asserted that these insurance carriers are continuing to exclude high-risk groups (and not just those with HIV) by making their insurance plans unaffordable. The good news is that at least 61% aren't playing that game - but you need to be aware of the plan you're choosing so you're covered for the meds and services you require.
AIDS Drug Assistance Program - ADAP
According to the National Alliance of State and Territorial AIDS Directors:
- ADAPs served over half of the individuals diagnosed with HIV in the United States.
- ADAPs serve over 140,000 clients each year by purchasing medications and/or health insurance for clients.
- There is still $310 million in additional funding needed to prevent new infections of HIV and Hepatitis and also to provide treatment. So the budget is tight and no significant increases are in plain sight.
- Total ADAP drug expenditures were $130,921,720 in June 2015 (according to the latest Annual Report).
ADAP continues to be financially strained and always at the mercy of both state and federal budgets. Although waiting lists decreased in most states from an all-time high in 2011 some wait lists may exist in certain states. Look at the ADAP list that follows for your state and check on the waiting lists and qualifiers.
Disability and Medicaid
Years ago, people with HIV were automatically assumed to be "disabled." Now, of course, they are not. But since issues like fatigue, depression and even diarrhea are very difficult to disprove, you can possibly be "disabled" by HIV if you need to be. Don't jump at it if you have other options! Disability becomes a trap that many people have a hard time getting out of!
When you go on disability, you may get cash income from Social Security, depending on how much other income you receive and what you own. But it's not much! To find out how much you may receive, contact your local Social Security office.
Qualifying for SSI usually also qualifies you for food stamps and - more importantly - Medicaid (which is called Medi-Cal in California and has different names in some other states as well.) Medicaid is a lifeline to HIV care for approximately 50% of people living with HIV (and 90% of HIV-positive children.) Medicaid pays for inpatient and outpatient treatment, home health care, prescription drugs and medical supplies.
If you're relying on Medicaid or plan to, ask your local ASO for help from a case manager who has experience dealing with your state's Medicaid program. It's complicated and getting more so! The Affordable Care Act (ACA) also affects Medicaid. The ACA cleared the way for all states to expand their Medicaid programs although some states aren’t willing to do so, which could shut out low-income individuals to access to health care coverage. The good news is that many states are expanding their Medicaid programs.
Patient Assistance Programs
Partnership for Prescription Assistance
Copyright 2017, Positive Health Publications, Inc.
This magazine is intended to enhance your relationship with your doctor - not replace it! Medical treatments and products should always be discussed with a licensed physician who has experience treating HIV and AIDS!