Using My Health Insurance
Maybe or maybe not. Not all doctors take all insurance coverage. Under some plans, you may be able to see any doctor you choose, but the amount you have to pay for your visits and the services you receive could vary depending on whether the doctor is in the plan’s network.
You should check with your doctor to see whether he or she takes any insurance plan you are considering. If your doctor does not accept your insurance, some insurance companies will let you submit the bill for reimbursement, but it probably will cover only a fraction of the cost of the visit. Other plans do not cover any costs when you see an out-of-network provider. It is also important to note that care received out-of-network may not count towards your out-of-pocket limit (the highest amount you would have to pay for care in any one year).
When you compare different plans in the marketplace, you will find a link to each plan’s provider network. Some health plan websites offer a provider search tool so that you can easily find out if your doctor is in its network. Before enrolling, however, it is strongly recommended that you call each of your doctors to double check whether they are in a specific health plan’s provider network. It is also a good idea to double check this information with any new doctor you might want to see and to ensure that they are accepting new patients.
There are two critical questions you need to ask about your medications. Are the drugs covered on the health plan’s formulary, which is the approved list of covered drugs? And how much will you be charged as a copayment or for cost sharing?
Under the Affordable Care Act, every insurance plan is required to cover at least one prescription drug in each category or class of drugs. This means that every plan will cover HIV medications, but not necessarily the specific drugs your doctor prescribes for you. All of the drugs that your plan covers are supposed to be listed by brand name and/or generic equivalent on your insurance company’s formulary or preferred-drug list. It is important to ensure you are looking at a complete (rather than a partial) formulary.
Most health plans in the marketplaces cover many HIV medications. The medications most often excluded are single-tablet-regimen combination therapies.
Many plans have placed all or nearly all HIV drugs on the highest cost sharing tier, which means that the amount they would charge you may be a big barrier to care. Some plans require that you pay coinsurance (or a percentage of a drug’s cost), while others require a copayment (a fixed amount). In most cases, you will pay less toward the cost of HIV medicines with a plan charging copays than with than a plan charging coinsurance.
Keep in mind that there is an annual out-of-pocket limit (the total amount you will have to contribute to healthcare costs each year) on spending for all people in marketplacehealth plans, excluding premiums. For 2018, this amount is $7,350 for individual coverage and $14,700 for a family policy. If ineligible for other coverage, people with incomes between 100 percent of the federal poverty level ($12,060 a year for a single person) and 250 percent ($30,150 for a single person) are eligible for cost sharing reductions (or CSRs) if they are eligible for a premium tax credit and purchase a silver plan through the health insurance marketplace in their state. Also, your state’s AIDS Drug Assistance Program (ADAP) may provide supplemental assistance for costs associated with prescription drugs and drugs not covered by a plan. Before enrolling in a health plan, try to determine how much you will be expected to pay for the medications you are currently taking.
- Insurance companies often limit the doctors in their health plan networks and require you to pay more to see a doctor who is “out of network.” Before selecting a plan, you should determine if your current doctor is in its network if you want to stay with that doctor. If you are already enrolled in a health plan and need to select a doctor, you should make sure that the doctor you select is “in network” for your specific plan. That means that the doctor and the plan have prearranged to work together. Sometimes doctors are in the network of some of an insurance company’s health plans, but not all. You should ask any doctors you are considering seeing whether they are “in network” for the specific health plan (not just insurance company) and metal level (such as bronze or silver, etc.) in which you have enrolled.
It is also important to find out if your doctor is your plan’s primary care or specialist category. Sometimes doctors specializing in HIV are in the specialist category, and it may be more expensive to see them or require a referral from your primary care physician. Some doctors are considered specialists for other patients, but health plans will allow them to be the primary care doctor for patients with HIV. In many cases it will save you money to sign up for a plan in which your doctor is categorized as a primary care provider.
You should also ask your doctor to perform needed health screenings and preventive measures, including vaccinations – such as flu shots – to prevent certain illnesses. Remember, health insurance can only help you stay healthy if you use it.
Insurance companies try to control costs for health care by limiting the drugs they cover. In some cases, if they do not cover all drugs in a class of drugs, they are able to get a bigger discount on those drugs they choose to cover. Every insurer must cover at least one brand of drug per class, but this does not necessarily mean it will be the drug that your doctor prescribes. Every insurance company has an appeals process in which you can challenge your insurer’s decision not to cover the drug you need. The process varies by company, but you can expect to need to give your insurer a letter from your doctor to justify your need for a specific medication. In urgent cases, your doctor can submit an expedited appeal. Check with your health plan to learn more about its appeals process. If an insurer denies an appeal, it is required to provide you with information about how to request an external review by someone who is independent of your health plan. Every state also has an independent appeals process through which your doctor can ask for an exception based on your medical need. Click here for more information about appeals.
Pre-exposure prophylaxis, or PrEP, is a once daily pill to help those who are HIV negative stay negative. Click here to find a PrEP provider near you.
PrEP is currently available under the brand Truvada. Most insurance companies and state Medicaid programs are covering Truvada as a way to prevent people from getting with HIV.
The Centers for Disease Control and Prevention (CDC) has issued criteria to health care providers determine about who would benefit from PrEP. If you meet these criteria or believe you would benefit from PrEP, discuss your options with your healthcare provider. Your insurance company may require prior authorization before covering the drug. If you plan on taking PrEP, check to make sure Truvada is listed on your plan’s formulary. Also, as with any medication, it is important to examine your cost sharing obligations before starting a regimen or when selecting a health plan, if you are already taking PrEP. Cost sharing for HIV medications, including Truvada, can be very high under some plans and, if you have not met a deductible, you could be responsible for the full price of this drug.
Not necessarily. First, if you don’t see the drug you take on a plan’s formulary, ask the company whether it has a separate list of specialty pharmaceuticals that it covers or if the list you are looking at is a complete formulary. If the drug is still not listed, you can appeal the denial of coverage.
Every insurance company has an appeals process in which you can challenge your insurer’s decision not to cover the drug you need. The process varies by company, but you can expect to have to give your insurer a letter from your doctor to justify your need for a specific medication. In urgent cases, your doctor can submit an expedited appeal. Check with your health plan to learn more about its appeals process. If an insurer denies an appeal, it is required to provide you with information about how to request an external review by someone who is independent of your health plan. Every state also has an independent appeals process through which your doctor can ask for an exception based on your medical need. Click here for more information about appeals.
Can my plan require me to get my medication via a mail-order pharmacy service rather than picking it up at a local pharmacy?
Starting in 2017, Marketplace plans cannot require you to use a mail-order pharmacy, if you would rather use a local pharmacy in person. However, it is often cheaper to use a mail-order pharmacy and have several months of prescriptions delivered at one time. In addition, you should check with your plan to make sure the pharmacy you want to use is in-network. Using an out-of-network pharmacy could result in much higher costs to you. In certain special circumstances, like if your medication requires controlled handling you may still be required to use mail-order services.
Most insurance companies can be reached by phone, email, online or by regular mail. Look at a company’s website or paper materials for its contact information. The toll-free customer service line is usually printed on the back of your insurance card. Communicating with an insurance company requires patience and sometimes multiple follow-up communication efforts to reach the right person who can help you. It might be helpful to keep a record of communication with your insurance company.
If something changes in my life, like my job, marital status or family size, do I need to notify my insurance company?
Yes. If you experience a qualifying life event, like a change in income, marital status or household size, you need to report this information to the marketplace so that your premium can be adjusted (for example, if you no longer have a spouse) and you can get the right premium tax credit, if you qualify for one. If you don’t update this information, you’ll get the same premium tax credit that was reconciled through last year’s taxes, even if you qualify for a larger or smaller credit. Whether you owe or are owed money back, it will be sorted out when you file your end of year taxes, if you do not address it proactively. If you want to add coverage for a new baby or drop coverage for a divorced spouse, you must also get in touch with your health plan.
Individual plans sold on and off the marketplaces cannot discriminate based on gender identity or sexual orientation.