Access to Health Care
No. Since implementation of the Affordable Care Act (ACA), insurance companies are no longer allowed to charge more based on a pre-existing condition—such as being HIV positive. (The only exceptions are plans that have been “grandfathered in” under the ACA.)
The only factors that health insurance companies are allowed to consider in pricing a plan, besides which level of coverage you select, are these: tobacco use, age, area where you live and whether you are enrolling individually or as a family.
If you make between 100% and 400% of the Federal Poverty Level (in 2015, for example, that was $11,770-$47,080 for individuals and $24,250-$97,000 for a family of four), the Affordable Care Act (ACA) provides subsidies to help cover the costs of insurance premiums. In states that have expanded Medicaid under the ACA, it is available to everyone below 138% of the Federal Poverty Level (or $16,243 for an individual). For a calculator to determine whether you qualify for subsidies, visit this website: www.healthcare.gov/lower-costs/.
Unfortunately, those who are making less than 100% of the Federal Poverty Level are not eligible for subsidies under the ACA. This is because the Congress that enacted the ACA did not consider the possibility that the U.S. Supreme Court would strike down the provisions requiring states to expand Medicaid. In states with expanded Medicaid, everyone below 138% of the Federal Poverty Level is eligible for Medicaid, so no one below 100% of the Federal Poverty Level needs insurance through the ACA marketplaces or the subsidies provided to buy that insurance.
To be eligible for Medicaid in a non-expansion state, a person must earn less than 100% of the Federal Poverty Level and be either disabled, a child or the head of a household that includes a child or children. (Note that the definition of “disabled” for purposes of Medicaid is different and harder to meet than the definition of a “person with a disability” under the Americans with Disabilities Act.) In these states, people who make less than 100% of the Federal Poverty Level but do not fit into one of the other categories are neither eligible for Medicaid nor eligible to receive subsidies under the ACA. Sadly, such individuals will need to continue to look to other sources to pay for health care services (see other questions in this section for more about that).
Yes, you can obtain care through the Ryan White HIV/AIDS Program. The specific benefits available through the program vary from state to state, but basic HIV-related care and treatment is available to everyone.
No, insurers must accept all such payments. After Lambda Legal successfully litigated a Louisiana case against one insurer that threatened to stop accepting such payments, the federal government issued new regulations requiring health insurers to accept payments from the Ryan White HIV/AIDS Program and certain other federal programs. If your health insurer is refusing to accept your payments, please contact Lambda Legal’s Help Desk.
No, your health insurance company is not permitted to tell your employer which medications you are taking, regardless of the cost or the health condition. Employers are allowed to review the claims history of their employees for the purpose of evaluating an insurance plan as a whole and comparison shopping, but employers are never supposed to have access to individual claim information.
If an employer has asked you to complete a form regarding your health care needs for purposes of its comparison shopping for health insurance plans, you should verify that the form will go directly to the insurance broker or other third party handling the employer’s purchase of health care and that the information on the form will not be shared with the employer until it has been aggregated and stripped of all identifying information.
Collect as much information as possible about the change in policy. For instance: When does the change go into effect? Is just one particular HIV medication affected, or are there other medications this insurance plan is not covering? Why is the employer discontinuing coverage? Is there a way to obtain a waiver so that you can continue receiving this medication?
After you have obtained as much information as possible, contact Lambda Legal’s Help Desk. Under current law, insurers are allowed to provide coverage for some HIV medications and not others, but there are certain minimum requirements they must meet. Lambda Legal and others are advocating for a policy that will require insurers to cover all non-experimental HIV medications.
Lambda Legal is not aware of an employer that has attempted to invoke “religious liberty” as a reason for denying its employees access to HIV-related treatments or prevention technologies. It is unclear how such a claim would hold up in court.