California is among the states moving forward with full implementation of the Affordable Care Act, which means that millions of uninsured and underinsured Californians, including many with HIV, will have access to insurance coverage for the first time. Beginning in January, California will expand its Medicaid program (Medi-Cal) to serve all legally present Californians who make less than 138 percent of the federal poverty limit (about $15,000 annually for one person). The state will also establish an insurance marketplace, Covered California, where people will be able to purchase insurance from qualified health plans. Changes brought about by the ACA will mean that plans can no longer turn you down or charge you more because you have a pre-existing condition. As a result, many uninsured people with HIV will now have a historic opportunity to secure health coverage that was previously unattainable.
At the same time, the ACA presents a significant challenge for some people with HIV who currently depend on Ryan White Treatment Modernization Act funding for their medical services. The Ryan White program is a "payer of last resort," which means that if someone is eligible for health care services under another coverage program, Ryan White funding can't be used to cover those same services. As a result, HIV-positive people who are newly eligible for insurance under health care reform will need to understand how their coverage may change. The new coverage begins January 1, but open enrollment for the expanded Medi-Cal program and Covered California plans begins October 1.
Understanding where you fit in health care reform
Most people with HIV will not see significant changes in their insurance. If you already have comprehensive insurance, Medi-Cal or Medicare, or some combination of those programs, you may have some new benefits and new protections (including a cap on the amount of money you spend out of your pocket on health care each year) but mostly your insurance will remain the same. People who depend on Ryan White or who are enrolled in Healthy San Francisco, which is not insurance coverage, could see some significant changes in their health care. People who are enrolled in the San Francisco PATH Program will be transitioned in to Medi-Cal. Undocumented immigrants are not eligible for the expanded coverage options under the ACA and will continue to rely on their current health care programs.
Your coverage eligibility is determined by income using your 2012 Modified Adjusted Gross Income (MAGI) found on your tax returns, and your best projection of your income in 2014. The National Alliance of State and Territorial AIDS Directors has resources available to help explain MAGI, including a mock MAGI calculation for those who haven't filed taxes. You may also be eligible to receive federal help with costs in Covered California based on your income. People who are newly married �" including some LGBT people who are now able to get married for the first time �" should probably talk with a tax specialist about how to calculate joint income. This is especially important if you qualify for the federal premium tax credits or subsidy assistance where projecting income accurately is important. It may be tempting to underestimate your income in order to qualify for a higher assistance level in the marketplace, but be aware that you may get hit with a bill at the end of the year if you do so. In order to avoid paying a penalty later on, you really want to make sure you're making the best estimate possible for your projected income.
Enrollment
Open enrollment starts next week, on October 1. Medi-Cal enrollment will happen continuously throughout the year but Covered California's enrollment period ends on March 31, 2014. If you don't enroll by that date, you will have to wait until the next open enrollment period in October 2014 before you can purchase coverage (unless you experience a significant "life event," for example a marriage, job loss, etc). In order for your Covered California plan to start by January 1, you need to enroll by December 15.
It is very important that everyone, especially people with HIV, take the time to carefully research plan options. You should also check with your provider and an HIV experienced benefits counselor or Covered California certified enrollment counselor prior to making any final plan decisions whether you will be moving to Covered California or to Medi-Cal.
There are three primary considerations for people with HIV when choosing a plan:
• Access to an HIV experienced provider and any other providers who are important to your care, including pharmacy, behavioral health, etc.;
• Access to necessary medications and;
• A complete understanding of the costs associated with coverage.
If you are entering Medi-Cal managed care, your plan choices are fairly limited �" there are only two Medi-Cal managed care plans available in San Francisco (the San Francisco Health Plan and Anthem Blue Cross). Access to an HIV experienced provider and any other providers who are important to your care will be your primary consideration.
In Covered California the choices are much more complex. Full plan information should be available at http://www.coveredca.com on October 1. It will be essential that people enrolling in Covered California get quality HIV specific benefits counseling in order to make the best plan choice. You and your benefits counselor or navigator may want to use the Marketplace Health Plans Assessment Worksheet to compare your options and identify the plan that is the best for you. Additionally, CoveredCA.com has a calculator that will help you determine how much the different plans will cost you.
The California State Office of AIDS has a premium payment assistance program for people with HIV called OA Health Insurance Premium Payment Program. If you enroll in the AIDS Drug Assistance Program �" available to those making $50,000 annually or less, OA HIPP will pay your insurance premium and ADAP will pay the co-pay for any drug that is also on the ADAP formulary. Piecing together OA HIPP and other federal help gets really complicated, which is why it is a good idea to seek out a benefits counselor to help you figure out the right plan.
If staying with your current provider is important you should call your provider's office now and ask which plans she or he is contracted with. That will narrow your plan choice. If you want or need to switch providers, do some research into the providers contracted with the various plan networks; you'll want to know what their experience is with treating HIV, and whether they are accepting new patients. As you are considering providers, make sure that you think about all the providers you use, including your pharmacy.
Another extremely important thing to consider when you're picking a plan is the formulary �" that is, what medications the plan covers. Most plans should cover HIV medications, but you also need to make sure all your meds are on the formulary.
Next year represents a great opportunity to gain secure, affordable health coverage for many more people with HIV. However, we also have a lot of work to do to ensure that people with HIV who are newly eligible for insurance make safe transitions to new coverage and that everyone continues to receive the quality HIV care that is necessary to improve health outcomes and reduce new infections.
This Guest Opinion is not intended as health care or legal advice for your specific situation. Anne Donnelly is director of health care policy at Project Inform; Courtney Mulhern-Pearson is director of state and local affairs at the San Francisco AIDS Foundation. For more information, visit http://www.projectinform.org or http://www.sfaf.org.