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HIV/AIDS

What if I didn’t enroll by the January 31st deadline?

For most people, the last day to enroll in a health plan for 2016 was January 31, 2016. But, in some cases, you may still be able to get coverage this year.

If you have a certain major life change, you may qualify for a special one-time opportunity to enroll after the deadline. These changes include losing your health coverage, getting married, having or adopting a baby, moving to a new place, having a change in your income, or gaining citizenship. Learn more about all the life changes here and remember that you have to enroll no later than 60 days after the major change happens. We also encourage you to take advantage of free help (either in-person or by phone) from a trained LGBTQ-friendly assister to help you understand your options.

In addition, you may qualify for free or low-cost coverage depending on your income and your state. You can get this type of coverage – through Medicaid or the Children’s Health Insurance Program – at any time during the year. Unlike the Marketplace, there’s no deadline and you can apply at any time. You can get more information here or can get free help from a local expert.

Will my plan cover PrEP (a prescription drug that can lower the risk of HIV)?

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 the prescription drug list (or “formulary”) to see where PrEP is listed and how much you might have to pay each month. If you need help, make a free appointment with an assister that 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.

What if I have a preexisting medical condition, such as HIV?

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.

Do I qualify for financial help to purchase health insurance through the Marketplace?

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 you and your spouse’s annual income is between approximately $16,000 and $63,000. In fact, over 8 out of 10 people who enroll through healthcare.gov qualify for financial help, find plans available for $75 or less per month.

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.

Do Marketplace plans cover benefits and services related to HIV?

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 will 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.

Will my prescription drugs be covered by my Marketplace plan?

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 will 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.

How can I find an LGBTQ-friendly doctor who takes my insurance?

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, you can check this list of providers provided by the Gay and Lesbian Medical Association (GLMA). A search for “Community Partners” on the GLMA list will also identify LGBT community health centers across the country. (GLMA does not screen each provider 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 to help connect transgender, gender nonconforming, intersex, and queer people to accurate, safe, respectful, and comprehensive care.

We also recommend that you contact your local Ryan White program to see if you qualify for additional financial help or benefits. 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 about your options and the benefits you might qualify for.

What if my plan refuses to cover the services that I need?

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:

  • Ask the insurer to reconsider its decision.
  • Know why an insurer denied your claim or ended your coverage.
  • Know how to challenge the insurer’s decision.

 

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, you can file a complaint of gender identity discrimination with the Office for Civil Rights at the U.S. Department of Health and Human Services. Read more here.

What if my plan doesn’t carry the prescription drug that I need?

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.

What should I do if I experience discrimination when using my coverage?

If you experience any form of discrimination, you should file a complaint with the Office for Civil Rights and let us know at info@out2enroll.org. It can be frustrating to file a complaint, but this is especially important given the lack of clarity about what must be covered. The more complaints, the more likely we are to get more guidance in the future.

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