POZ Community Forums
Main Forums => Living With HIV => Topic started by: LordBerners on February 20, 2009, 12:24:50 pm
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I have a question regarding access to Medicaid coverage of HIV treatment in the US. I understand you have to be considered 'permanently disabled' to recieve this covereage, and that an 'aids diagnosis' may in most cases be considered permanently disabled. I have recieved such a diagnosis in the past year, but from doctors here in Thailand. My health is fine now, but if I return to the US, will I be able to gain access based on this past aids diagnosis, or must I wait for another? Or does one always get removed from Medicaid coverage once one's T-cells bounce above 200?
Please excuse and ignore if this question is considered inappropriate, is answered elsewhere, or if my above assumptions are incorrect.
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If you have money and money in a checking and savings account then you won't be able to get Medicaid. You also have to have paperwork signed by your doctor that you are unable to work.
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If you have money and money in a checking and savings account then you won't be able to get Medicaid. You also have to have paperwork signed by your doctor that you are unable to work.
Ah, thanks Rapid Rod. I have no money, of course, but the latter requirement you mention will probably preclude access to health care through this program.
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Medicaid eligibility is actually determined by individual states and it varies. You have to be living below the poverty level is a universal requirement. In terms of disability requirements this varies from state to state. If you are thinking of moving to a particular state then I'd check out their particular medicaid requirements on their state gov. website under department of human services. Due to the economy the eligibility requirements have been in a state of flux---children being the highest priorty. Will be interesting to see how Obama's stimulus package shakes down in terms of availability of medicaid dollars to the states but we could see a rise rather than a decrease from the last administration. At least I hope the trend to balance the federal and state budgets on the backs of the poor will be curtailed.
rick
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Actually you really never now if you will be approved. I was approved for SS because of my AIDS diagnosis. Even though my numbers have risen above 200 they do not take it away. I was also denied medicaid not because I have money because I don't. My savings account is depleted and my husband only shows $450 a week.
I do however have medicare after 2 years on SS and also receive ADDP which helps with my medication
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I appreciate your reply, franfrog, but I didn't precisely understand it. It sounds like everything's working out for you though
I'm just contemplating a return to the US because my treatment options are dwindling here in Thailand, though life is far better here. Before I make the unpleasan leap of returning home I'd like to determine if I would have a good chance to get treatment in the US, but it seems its a bit hard to be sure of anything.
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That is exactly;y my point. There is no way to know. Some people who have more money then I do are receiving medicaid as where I am not. I am considered "permanently disabled" and still can not get it. As for the SS, there are people that I have spoken to that are in far worse shape then I, and are having trouble getting SS where I was approved within 3 weeks of filing. It depends on where you plan on going and what you may be eligible for. There is really no way to tell.
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Lord Berners:
I think in your initial post you are bringing up two separate issues: Medicaid and Disability. They're not the same thing. Medicaid varies state to state, as one poster has already mentioned, and it is based on income (which also varies but basically must be very low, i.e . poverty level or close to that). In some states you are allowed to own a house and a car but you can't have much (or anything) in the way of other assets or savings etc. If you qualify financially, then you get Medicaid, in other words you don't have to have an AIDS diagnosis, etc. A friend of mine was recently diagnosed as HIV+, he does not have an AIDS diagnosis and has not gotten sick with any OIs but he did require ARV medications. His income was low enough that he qualified for Medicaid and he is now receiving his medications paid for by his state's Medicaid (as well as his doctor visits and all the other healthcare he needs). As far as Disability, that's slightly more complicated and does require certain medical pre-conditions, etc
The other thing for you to consider if you were to come to the US is ADAP. It also varies by state as far as income eligibility (and some ADAPs now have a waiting list). I was recently told by someone who knows about such things (though I have not confirmed it), for example, that in the state of Colorado, ADAP does not look at assets at all and the income limit is 400% of the poverty level (which is about $41K annually), I think Connecticut may be similar. Most other ADAPs will look at assets apart from one's income so you are only allowed to have a small amount in savings or 401k, etc). If you have some money in the bank, you can always buy a house (or condo, etc) since that's usually allowed with both Medicaid and ADAP (and make sure of that first since there are slight variations state to state) The link below has some useful info on this stuff:
www.atdn.org
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Thanks for you comments, InchlingBlue. There's no problem about 'assets' or money in the bank here - I'm a destitute.
But when I was talking about 'being disabled' I wasn't talking about disability as in the Social Security Disability sense. It is my understanding that the great majority of states, if not all, require that you be disabled (unable to work) in order to receive Medicaid coverage. This is, as I understand it the age-old Catch-22 of Medicaid for hiv sufferers - you can't get ARV to prevent AIDS while you're still relatively healthy - you have to wait until your health declines. This is one of the big reasons ADAP/Ryan White was started, if I'm not mistaken.
However, the reason I'm so concerned about Medicaid is that, as I understand it, ADAP only pays for medicines, not for the related doctor's appointments, blood testing, etc. So I wouldn't be able to afford those without some other coverage.
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LordBerners, you have received several excellent responses to your question. My echo of those is to look up each states Medicaide requirements.I am in North Carolina This is how my medicate works: Bear in mind I am female and have a 5 year old son and that does have bearing on my case. I have received Medicade since 2005, The Medicaid office sent my doctor a letter, which he filled out and returned. All of my doctors appointments are covered ( with a 3 dollar copay), Medicade will cover most medicines, my Atripla, is covered(3 dollar copay). Usually they want you to take a generic or will only pay for a partial refill on certain meds. I never received a aids diagnoses even though my CD4 fell below 200, I have had no OI's, I am able to work parttime but my line if work rarely offers any sort of benefits(Restaurant work) Hope that helps, I would look up whatever state you are considering moving to and seeing how their Medicade works. Best of luck to you. Cristy
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However, the reason I'm so concerned about Medicaid is that, as I understand it, ADAP only pays for medicines, not for the related doctor's appointments, blood testing, etc. So I wouldn't be able to afford those without some other coverage.
Wrong. Ryan White/ADAP covers meds, bloodwork and related Dr. appointments.
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Wrong. Ryan White/ADAP covers meds, bloodwork and related Dr. appointments.
Only as a last resort. If there's other funding/coverage available that must be used first as the Ryan White legislation is written. That's probably the source of the confusion for many people, though assuredly Auntie D knows all of this :)
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Only as a last resort. If there's other funding/coverage available that must be used first as the Ryan White legislation is written. That's probably the source of the confusion for many people, though assuredly Auntie D knows all of this :)
That's correct, My Medicare is always used (bill-to) before RW is even considered. and most of the time RW isn't even used in my case at all.......
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Other than having private health insurance, there are three main ways in which people with HIV/AIDS receive health care:
1) Medicaid- This is a "safety net" coverage for individuals with low income, the specific income amounts and coverage vary state to state but overall it's the same thing: if you make very little money and have no assets (most states allow one house and one car) then you qualify and your meds and other healthcare are covered, maybe with some reasonable co-pays, but you are covered if you qualify financially. You don't have to be disabled or have an AIDS diagnosis, being HIV+ is enough. You are allowed to work but the catch-22 is that you must not earn very much money, which makes it difficult as far as you have to earn a low enough amount to qualify and yet high enough to pay whatever bills you have etc. It sounds like this may be your best bet as long as you are able to establish residency somewhere ASAP (I think it takes about 6 months to establish legal residency in most states).
2) Medicare and Social Security Disability Insurance (SSDI)- Mecdicare is either for people 65 and over or for people who have been medically declared disabled. Unless you are 65 or over, here you do need to be more than just HIV+ in order to qualify (i.e. an AIDS diagnosis, etc). As far as I know, you are not allowed to work if you are receiving disability benefits. The benefits include a monthly check for living expenses.
3) Ryan White Care Act/ADAP- Many people who don't qualify for Medicaid and are not officially "disabled" qualify for this coverage, varies state by state. Based on income usually 300% or 400% of the poverty rate. They do cover doctor visits and blood work etc., but, as someone said in an earlier post, they do it as provider of "last resort" meaning only if you prove to them that you do not qualify for anything else. Usually they need to see a letter that you have been rejected for Medicaid before they approve you (but many ADAPs will supply one months worth of ARV meds for free if you are waiting to hear back from Medicaid).
Some people have a combination of two or more types of coverage with one of them as "primary." For example, if you are over 65 and poor you can have both Medicaid/Medicare. And denb45 (above) has Ryan White and Medicare. There's a thread started by Peter Staley called "Updated HIV/AIDS Fact Sheets On Medicaid, Medicare, and Ryan White" which has a good overview of all of this. Hope this helps........maybe Medicaid is your best bet if you have very low income and little or no assets?
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That's correct, My Medicare is always used (bill-to) before RW is even considered. and most of the time RW isn't even used in my case at all.......
I'm curious about that "donut hole" I keep hearing about with Medicare. Do you have to pay out of pocket at the beginning of each year until you have paid out the amount known as the "donut hole"?
Thanks in advance for the info ;)
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I'm curious about that "donut hole" I keep hearing about with Medicare. Do you have to pay out of pocket at the beginning of each year until you have paid out the amount known as the "donut hole"?
Thanks in advance for the info ;)
If you qualify for State Medicaid or RW, both programs will pay for your HIV Meds depending on your income.....the "Donut Hole" only applies to anyone that's on Medicare Part D, that's what I have, but, "Extra Help" pays for my "Donut Hole" and that's a part of the Social Security Administrations "Extra Help" and you only get that, if your SSI/SSDI income qualifies, and you are on Medicare Part D... if you do not qualify for "Extra Help" you could end up in the "Donut Hole" that means you could pay-outta-pocket (2,000 to 4,000 for MEDS, if you reach that, most don't) what this means is you will have VERY LARGE MED CO-PAYS...........I hope this info clears up all the confusion ;D
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Note a couple of clarifications
1) Medicaid- This is a "safety net" coverage for individuals with low income, the specific income amounts and coverage vary state to state but overall it's the same thing: if you make very little money and have no assets (most states allow one house and one car) then you qualify and your meds and other healthcare are covered, maybe with some reasonable co-pays, but you are covered if you qualify financially. You don't have to be disabled or have an AIDS diagnosis, being HIV+ is enough. You are allowed to work but the catch-22 is that you must not earn very much money, which makes it difficult as far as you have to earn a low enough amount to qualify and yet high enough to pay whatever bills you have etc. It sounds like this may be your best bet as long as you are able to establish residency somewhere ASAP (I think it takes about 6 months to establish legal residency in most states).
Medicaid unfortunately does not automatically cover everyone who earns very little money. Each state is required to cover children, pregnant women, parents of children and disabled adults. The missing group is unmarried adults who do not qualify for disability. That includes a lot of people who read these forums.
Only 35 "states" also cover medically needy adults who are not disabled or parents. The chart in the file Peter provided from the Kaiser Family Foundation clarifies this.
http://www.kff.org/hivaids/upload/7172_04.pdf
2) Medicare and Social Security Disability Insurance (SSDI)- Mecdicare is either for people 65 and over or for people who have been medically declared disabled. Unless you are 65 or over, here you do need to be more than just HIV+ in order to qualify (i.e. an AIDS diagnosis, etc). As far as I know, you are not allowed to work if you are receiving disability benefits. The benefits include a monthly check for living expenses.T
Medicare eligibility is based on eligibility for Social Security benefits (but requires a longer period to qualify unless you have End Stage Renal Disease).
To start receiving disability benefits you need to have paid into Social Security at a minimum level for 5 to 10 years (varies based on age) and be unable to work.
Once you start to receive benefits you can continue to receive Social Security disability benefits and earn some income but not much. The rules are complex and require that a person not be able to work in "substantial gainful employment". Among other restrictions this means you cannot earn more than $980 per month (in 2008). An explanation of the rules is on the Social Security website http://www.socialsecurity.gov/dibplan/dqualify5.htm
I'm curious about that "donut hole" I keep hearing about with Medicare. Do you have to pay out of pocket at the beginning of each year until you have paid out the amount known as the "donut hole"?
The Kaiser Family Foundation also has a fact sheet on the Medicare Prescription Drug program. http://www.kff.org/medicare/upload/7044_08.pdf (http://www.kff.org/medicare/upload/7044_08.pdf) People in standard Medicare Prescription Drug Plans pay 100% for the first $275 of drugs, 25% of the next $2200 or so, then 100% of the next $3300 or so (the donut hole) then 5% of any additional drug costs.
Many people are not in standard Prescription Drug Plans, but have similar rules and a donut hole.
Berners
The upshot of all this is that it might be best to choose a few likely places where you might want to relocate and then research the options available there. Each state has its own rules and various local and ASO programs are on top of those.
A
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Berners
The upshot of all this is that it might be best to choose a few likely places where you might want to relocate and then research the options available there.
Thanks for your detailed explanations, Assurbanipal. Unfortunately I could not choose where I would go as I must return to my home state and the bosom of my family (there would be no other way to afford to live in the US except for in said bosom). Alas my home state of Missouri does not appear to provide any Medicaid coverage for single destititutes such as myself, but Illinois right next door does and my home is on the border so something could probably be worked out.
As for social security disability, alas I have not worked long enough in the US to 'have paid into the system' for a sufficient amount of time to be allowed access.
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Just wondering if you have reached out to the local ASO's where your family lives to see what other resources might be available besides Medicaid (clinics, etc.)?
If you go to the directory link on this site you can enter a zip code and see ASO's that are nearby. http://directory.poz.com/
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Assurbanipal: Thanks so much for clarifying my post........I've read some of your older posts and they're all so informative, interesting and helpful. ;)
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Berners--if you have not worked long enough in the US to qualify for social security disability then you would apply for supplemental security income through social security. It is generally a lesser amount. The application process usually takes time and you may go through an initial denial and have to appeal but most people who are disabled who apply will get it eventually. Best of luck.
rick