Medications prescribed by your doctor, including antiretrovirals for the treatment of HIV. Plans will vary in the specific drugs they cover.
Overnight hospital stays, often called inpatient care. These benefits are especially important because the Ryan White HIV/AIDS Program is prohibited from paying for hospital care.
Services typically provided in a doctor’s office, or at a hospital on an outpatient basis. Often called doctor benefits, they are used to prevent, diagnose or treat health conditions. For financial and other reasons, many people with HIV do not have a regular doctor to monitor and treat them. A regular doctor is essential for quality medical care and is covered under this benefit.
Services provided in a hospital emergency room (ER) to treat an urgent or life threatening condition.
Services from psychiatrists, psychologists and other mental health providers, and for treatment of alcohol and drug dependency and abuse. Mental services can also include counseling for specific HIV-related problems, such as dealing emotionally with a diagnosis or working through issues communication in a relationship.
Tests and diagnostic services such as x-rays, CD4 counts, and viral load tests ordered by your doctor.
Services provided during pregnancy and after childbirth, including services for delivery of newborns. Maternal and newborn care is especially important for women living with HIV, because with proper treatment, HIV-positive women are far more likely to give birth to healthy, HIV-negative babies.
Services such as vaccines–including flu shots, hepatitis vaccinations and more–and other prevention services like HIV screenings, cancer screenings and preventive services for women. All private health plans other than those that existed prior to March 23, 2010 and have “grandfathered” status must provide coverage for these preventive services and may not charge you anything when you receive them. This includes any new employer-based insurance, and any employer-based insurance that has changed significantly since 2010.
Services to help people regain or maintain their ability to function and perform activities of everyday life. For example, physical or occupational therapy for recovery from an injury or to help those with disabilities maintain their ability to perform a key function, such as walking.
Medical services provided to children, including dental and eye care, services to support healthy development and services to treat any disease or condition.
While all plans must cover all of these categories of benefits, they are not required to cover all services within a category. Health plans are permitted to establish their own rules for determining when a service is eligible for coverage. Federal rules set higher standards for some benefits. For example, every health plan must cover at least one drug in each drug class, but they are not required to cover all drugs within a class. People with HIV depend on broad access to prescription drugs. Health insurance plans may establish what’s known as a ‘formulary’, a list of the specific drugs they will cover. The plans must also establish review procedures to ensure that you have access to all medications you need in cases when there are no acceptable substitutions even if they are not included on your plan’s formulary.