To make sure you have health insurance for 2023, you have to enroll between November 1st, 2022 and January 15, 2023. If you miss the deadline, you could be locked out of health insurance until 2024 AND forced to pay 100% of your medical bills. It’s not worth the risk, especially when financial help is available: last year, 4 out of 5 HealthCare.gov customers could find a plan with a monthly premium of $10 or less thanks to the American Rescue Plan Act.
Insurers cannot refuse to sell you a plan or charge you more just because you have a preexisting condition such as HIV, cancer, or even asthma. This is true even if you have been refused coverage in the past. If you face discrimination at any point during the enrollment process, please let us know at info@out2enroll.org.
Yes, you may be eligible for financial help to make your coverage more affordable. The amount of financial help depends on your income. You may qualify for financial help if your annual income is between about $12,000 and $51,000 (or more based on the number of people in your family). In fact, nearly 9 out of 10 people who enroll through healthcare.gov qualify for financial help, and 4 of 5 people are able to find a plan with a monthly premium of $10 or less. Learn if your income level qualifies you for savings here.
If you qualify, you will receive a tax credit that lowers the amount that you pay for insurance each month. Depending on your income, you may also qualify for cost-sharing reductions that lower the amount you pay in co-pays, deductibles, and other out-of-pocket costs. Learn whether you might qualify for financial help using this quick calculator.
You may also qualify for even more benefits through your local Ryan White Program, including lower monthly premiums or out-of-pocket costs for prescription drugs. Find a Ryan White program near you to learn more about your options.
The coverage of HIV-related care continues to vary by state. However, plans sold through the Marketplace have to cover a minimum set of essential health benefits. These benefits include prescription drugs, mental health care, and chronic disease management.
The Affordable Care Act also prohibits insurers from placing lifetime and annual dollar limits on essential health benefits. This means you can no longer “max out” of care that you need. Because benefits vary by plan, we encourage you to take advantage of free help (either in-person or by phone) from a trained assister to help you consider your options.
It depends on your plan. Every plan sold in the Marketplace must provide a link to its drug formulary (the list of drugs that are covered). If you need a certain drug, you can check this formulary to find out if it is covered before you sign up for coverage. It is also very important to see what “tier” level your drugs are on – those at the higher or specialty tiers may require you to pay higher out-of-pocket costs.
Because prescription drug coverage vary by plan, we encourage you to take advantage of free help (either in-person or by phone) from a trained assister to help you consider your options and contact your local Ryan White program.
Every plan sold in the Marketplace must provide a link to its directory of health providers. If you already have an LGBTQ-friendly provider that you know and trust, you can use this directory to find out if your provider is included before you sign up for coverage.
To find an LGBTQ-friendly provider, check out this list of providers by GLMA: Health Professionals Advancing LGBT Equality. A search for “Community Partners” on this list will also identify LGBT community health centers across the country. (GLMA does not screen the providers and therefore cannot make any guarantees about their services, but all providers on the list have affirmed their commitment to LGBT health as a condition of being listed in the directory.) You can also check out RAD Remedy, a directory that helps connect transgender, gender nonconforming, intersex, and queer people to accurate, safe, respectful, and comprehensive care.
Depending on your state, the Ryan White program may help lower your monthly premiums or your out-of-pocket costs for prescription drugs. Contact your local Ryan White program to learn more and see if you qualify for additional financial help or benefits.
If your plan refuses to cover medically necessary services that are recommended by your doctor, you have the right to appeal this decision and have it reviewed by an independent third party.
You have the right to:
Typically, you must first go through a process called the “internal appeals process” where you appeal directly to your insurer. If you are unhappy with the result from the internal appeal, you can then request an “external review” from an independent third party.
We recommend going through this process because many denials are overturned during the appeals process. If you need help filing an internal appeal or external review, contact your state’s consumer assistance program or insurance department.
If you are denied coverage for transition-related care or discriminated against at any point in this process, contact a legal organization here. Read more about your rights here and here.
Every plan sold in the Marketplace must provide a link to its drug formulary (the list of drugs that are covered). If you need a certain drug, you can use this formulary to find out if your drug is covered before you sign up for coverage. If you have a specific health need, we encourage you to take advantage of free help (either in-person or by phone) from a trained assister to help you consider your options.
If your doctor prescribes a drug for you but your insurer doesn’t cover the drug, you may be able to appeal for an exception to get the drug covered. To do so, contact your insurer. If you want help with your appeal, contact your state’s consumer assistance program or insurance department.
If you experience any form of discrimination, you should contact a legal organization here and let us know at info@out2enroll.org. You should never face discrimination when it comes to health insurance or health care. Learn more about your rights and what you can do to fight discrimination at the National Center for Transgender Equality’s Health Care Action Center.
Most plans will cover PrEP (also known as Truvada) but your monthly costs may vary, depending on which plan you choose. Before you enroll, make sure to check your plan’s prescription drug list (or “formulary”) to see where PrEP is listed and how much you might have to pay each month. You can also visit prepcost.org to help you choose the best marketplace health plan for you. If you need help, make a free appointment with an assister who has been trained to answer questions about what services are covered for LGBT people. And check out this easy tool to find a doctor or other provider in your area who prescribes PrEP.
If you don’t have health insurance but still want to take PrEP, or if it is too expensive for you even with health insurance, you may qualify for financial assistance directly from Gilead, the company that makes Truvada. Learn more here or contact your local HIV/AIDS service organization or Ryan White center.
