Currently, under the Affordable Care Act, employees living with HIV or AIDS can not be denied health care coverage based on their condition. However, even with insurance coverage, costs can escalate quickly if employees don’t adopt a proactive approach to their care.
Thankfully, there are certain protections in place for employees with preexisting conditions, including HIV and AIDS. For instance, individuals might be able to get help paying for their HIV or AIDS medications. They also can receive continuity of care if they choose to switch plans or networks.
Let’s examine a few ways in which employees living with HIV or AIDS can receive the care they need.
Employee Health Insurance
The rules for small group health insurance policies in the State of California are different from large group or individual health insurance policies in several ways ― one of which is that individuals with preexisting conditions (including HIV or AIDS) cannot be denied guaranteed coverage through their employers’ small group policies.
However, whichever insurance company your business chooses to work with has the option to implement a six-month waiting period for individuals with preexisting conditions. Thankfully, if the employee has uninterrupted prior group coverage for at least 180 consecutive days, this time can be applied to decrease or eliminate this waiting period.
COBRA and Cal-COBRA
Employees covered under a group insurance plan from their employers are protected under the Consolidated Omnibus Budget Reconciliation Act (COBRA), which is a federal law extending coverage in the event that an employee is terminated or has their hours reduced to part-time status. Obviously, this can be a lifesaver for individuals who have been diagnosed with HIV or AIDS and are undergoing treatment for their condition, especially since this extension period lasts for at least 18 months (or 36 months for Cal-COBRA) and perhaps even longer for individuals with qualifying life events.
To be eligible, a policy must cover at least 20 employees who were covered during more than 50% of business days throughout the previous calendar year. The requirement for Cal-COBRA is slightly more lenient, as it requires only 2 to 19 employees being covered during more than 50% of business days throughout the previous calendar years. However, individual health plans are not covered under COBRA or Cal-COBRA, so this could be something to consider when employees are deciding whether or not to participate in a small group health insurance plan through their employer.
AIDS Drug Assistance Program
Individuals with HIV or AIDS might be eligible to receive payment assistance for their medications through the AIDS Drug Assistance Program (ADAP), which offers people who are uninsured or underinsured access to vital medications. Individuals with gross incomes up to 500% of the federal poverty level could qualify for drug deductible and copayment assistance for medications listed on the ADAP formulary. However, the individual’s insurance plan’s pharmacy must be a participating ADAP pharmacy.
Individuals enrolled in ADAP are also eligible to receive assistance with their monthly premiums through the Office of AIDS’ Health Insurance Premium Payment program. In addition, individuals might also be eligible for assistance with outpatient medical out-of-pocket costs. Any questions, concerns, or issues related to payment can be directed to whatever health insurance company they’ve chosen.
Continuity of Care
Individuals with HIV or AIDS may be eligible to receive up to 12 months of “continuity of care,” which allows people with serious chronic conditions to continue on their care plan after switching to a new plan or changing their provider, hospital, or pharmacy network. However, these persons must request continuity of care with their previous plan or network, and their provider or hospital must first agree to retain them as a patient.
If an individual’s plan or network denies their request or fails to respond in a timely fashion, they have the right to file an appeal through their health insurance company. And if the appeal is not resolved to the consumer’s satisfaction, further action can be taken by contacting the California Department of Managed Health Care’s Help Center at (888) 466-2219.
New plans will likely continue to cover a consumer’s medications, but the formularies do change periodically. Individuals should first contact their health insurance provider with any questions they might have about their medications. If their provider refuses to continue drug coverage, the same appeals process detailed previously becomes applicable.
Contact Canopy Health: Refreshingly Clear, Human Care
At Canopy Health, we are sympathetic to individuals living with chronic preexisting conditions, especially those living with HIV or AIDS. Everyone has the right to gainful employment and quality medical treatment, and we would love the opportunity to speak with you about how we can provide your staff with refreshingly clear, human care.