POZ Community Forums
Meds, Mind, Body & Benefits => Insurance, Benefits Programs & HIV => Topic started by: Tim Horn on March 27, 2010, 08:47:55 am
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Okay, I'm going to start up another thread regarding health care reform, given that two threads started earlier this week needed to be shut down because the rhetoric started to spiral out of control. As controversial as HCR may be, it is now law in the United States. And because it does have many implications for people living with HIV, it absolutely must be discussed and understood.
I know that policy wonks at a number of AIDS organizations are scrambling to make sense of the legislation. Fact is, the details of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 are fuzzy and it is not yet clear how things will change over the next several years for people living with HIV. For example, many people living with HIV will soon qualify for private health insurance without the risk of lifetime caps, possibly with subsidies -- this may change ADAP requirements throughout the U.S.
I'm working to find someone who can spell all this out in a detailed overview for AIDSmeds and POZ. In the meantime, I've been relying heavily on some extremely helpful overviews produced by the Kaiser Family Foundation:
Kaiser Family Foundation's Health Care Reform Page (http://healthreform.kff.org/)
Please -- feel free to use this thread to ask questions about HCR and discuss your understanding of what the legislation means for us.
I'm requesting that this thread remain informational and educational in nature. While it's difficult to keep politics out of threads such as this, I'm asking that anyone who wishes to debate the merits of health care reform in the United States do so elsewhere, preferably in clearly defined threads started in the off-topic forum. It's basically up to you guys to keep this thread on course.
Tim
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The part of the bill that interests me is the provision that folks without insurance (me) and a preexisting condition (me again) will be able to acquire it through a high risk pool withen ninety days. It looks like there will be subsidies provided for folks on the lower end of the economic scale (definately me) to make it affordable. Also if I read the bill correctly, folks over a certain age and making under a certain amount will have the option to obtain medicaid. Not sure about that one. Anyway, I can't wait. I've been without insurance for a decade.
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Where can I find information regarding how this will affect people like my wife and I, who fall under the so-called "middle class" with insurance? We are slowly sinking into major debt because of our medical bills and I would like to find out if any of this will bring relief to us, but I don't know exactly where to look.
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Skeebo:
There's a lot of really great information on the Kaiser site I link to above.
I suppose it all depends on the factors are at play here. For example, if you're facing medical bills because of annual (or lifetime) limits of coverage, the passed legislation will certainly remedy this. It also prohibits rescissions of coverage.
Here's a comprehensive, yet simplified, review of the legislation: http://www.kff.org/healthreform/upload/finalhcr.pdf (http://www.kff.org/healthreform/upload/finalhcr.pdf)
Here's a good timeline of the HCR roll out: http://www.kff.org/healthreform/8060.cfm (http://www.kff.org/healthreform/8060.cfm)
Tim
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Skeebo:
There's a lot of really great information on the Kaiser site I link to above.
I suppose it all depends on the factors are at play here. For example, if you're facing medical bills because of annual (or lifetime) limits of coverage, the passed legislation will certainly remedy this. It also prohibits rescissions of coverage.
Here's a comprehensive, yet simplified, review of the legislation: http://www.kff.org/healthreform/upload/finalhcr.pdf (http://www.kff.org/healthreform/upload/finalhcr.pdf)
Here's a good timeline of the HCR roll out: http://www.kff.org/healthreform/8060.cfm (http://www.kff.org/healthreform/8060.cfm)
Tim
Thanks Tim, if I am understanding this correctly annual limits will be eliminated by 2014.
Edited to add: I've reviewed it further and it looks like our annual limit would remain effective even after 2014. From what I gather, it seems to state the limit cannot exceed $2000 annually per individual, $4000 family. Our limit right now is $2500, which we usually meet around the end of the fiscal year, just in time for it to reset.
So I don't stray this topic on my own individual needs if I am missing something, please provide me any info to the contrary via PM. Indeed, I do hope I am wrong about this.
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Can anyone tell me about prescription coverage?
I have GHI with no prescription coverage, my union provides me with a plan through express scripts that gives me 7500 per year in prescriptions. From there my union has me enrolled in a group catastrophic plan that pics up once the other insurances run out up to 2million dollars. Right now my meds are 18000 per year. My catastrophic picks up 11,500 of that. Im afraid i am going to lose the group plan with this new legislation and have to pay that myself. I called my union and nobody can tell me an answer to what is going to happen because there are so many unanswered issues in this bill.
Anyone have any insight?
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Thanks Tim, if I am understanding this correctly annual limits will be eliminated by 2014.
Edited to add: I've reviewed it further and it looks like our annual limit would remain effective even after 2014. From what I gather, it seems to state the limit cannot exceed $2000 annually per individual, $4000 family. Our limit right now is $2500, which we usually meet around the end of the fiscal year, just in time for it to reset.
So I don't stray this topic on my own individual needs if I am missing something, please provide me any info to the contrary via PM. Indeed, I do hope I am wrong about this.
By "annual limit" health care reform refers to the maximum amount that the plan will pay in benefits per year. Most plans today have a lifetime limit of between $1 and $5 million in benefits. This is no longer allowed under the new law effective within the 2010 year. Also for 2010 plans can only have annual limits on what they will pay per year that are "reasonable" Kathleen Sebelius, the Secretary of Health and Human Services ,will issue regulations that say what is a "reasonable" annual limit is.
It sounds like you are more interested in the limits on what you will pay.
If you get your health care coverage from an employer plan, what you pay comes in four forms:
- some plans charge you a monthly premium
- most plans only start to pay benefits once you have already paid some amount without any help from them -- the amount you pay before the plan pays anything is called your deductible The $2,000 and $4,000 amounts you refer to above are the new maximum deductible amounts starting in 2014 for group insurance plans sold to small employers
- many plans require you to still pay a fraction of health care costs when they start to pay benefits at all -- these payments are your co-insurance amount
-- or they may require you to make a flat payment (e.g. $10) each time you get care -- these payments are called co-pays
- many plans today, and the new insurance plans that are sold on the exchanges in 2014, have a maximum limit on what you are required to pay in a year -- this is the maximum out of pocket limit. Once your deductibles, co-pays and co-insurance reach the mamximum out of pocket limit the plan pays everything until you reach the annual or lifetime limit on plan payments.
So the maximum on how much you will pay in the future will be whatever you pay in premiums plus your out of pocket maximum.
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You are right Mr. Urban, it is the deductible I was referring to. Are the annual deductibles going to be eliminated? Right now our monthly premiums are $596 monthly. The co pays are all fine and understandable, but it is the deductible portion of our plan that really is killing us. When I see my doctor at the beginning of the year I pay $150 out of pocket, and of course this does not include any of the lab costs and such. There are 3 on the policy, of which 2 of us require constant medical attention... this is what is giving my wife and I fits. My little one recently had pneumonia and the X-ray alone cost me over $300 out of pocket... once again because we had yet to meet the deductible set forth by our plan. By the time we reach the $4000, of which co pays don't go against, it's already time for it to reset.
It's gotten to the point where the only thing I let my doctor check are my Cd4's and Vl, it's just that bad. :(
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I think Assurbanipal explained the basics of health insurance coverage beautifully.
Fact is, many insurance companies will continue business as usual -- some offer plans with higher premiums but with lower co-insurance and co-payment amounts; others offer plans with lower premiums with high co-insurance and co-payment amounts.
What's really important here is not only are people living with HIV basically guaranteed health insurance, they will have the option of choosing the best policy to suit their needs (and the needs of their families, if dependents are involved). For example, if you're working for a company offering an insurance plan that simply doesn't meet your needs, and your income is within 400 percent of the federal poverty line (e.g., a household of two making less than $58,280), employers are required to provide a free voucher (the payout must be the same as the policy offered by them) that can be used to buy insurance in the state-run Exchanges that will be set up.
Tim
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Can anyone tell me about prescription coverage?
I have GHI with no prescription coverage, my union provides me with a plan through express scripts that gives me 7500 per year in prescriptions. From there my union has me enrolled in a group catastrophic plan that pics up once the other insurances run out up to 2million dollars. Right now my meds are 18000 per year. My catastrophic picks up 11,500 of that. Im afraid i am going to lose the group plan with this new legislation and have to pay that myself. I called my union and nobody can tell me an answer to what is going to happen because there are so many unanswered issues in this bill.
Anyone have any insight?
It sounds like the union is the official plan sponsor of your catastrophic plan? If so, they will have to remove the $2million limit on what the plan pays but not be forced to do much else before 2014.
One of the problems for the union, though, is that the catastrophic plan is currently written to pick up and provide you with benefits where the Express Scripts plan leaves off, when the Express Scripts plan hits its annual limit of $7500.
There will be new rules, coming out soon, that might make Express Scripts change the $7500 annual limit, if it is not "reasonable". But there's not much info or even informed speculation on what a reasonable limit will be yet. But it goes into effect quickly.
So at this point, the union is waiting to find out what Express Scripts is going to do and then figure out what they can afford to do in response. Express Scripts is waiting to find out what a reasonable annual limit will be...
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Are the annual deductibles going to be eliminated? Right now our monthly premiums are $596 monthly.
Sadly, no. The legislation gives government the right to review premium increases it deems unreasonable. But it doesn't give it the right to roll them back.
But again... you will at least have the option of shopping around for a (hopefully) kinder, gentler policy. And depending on your income, this might include a credit to purchase insurance through the Exchanges (see: Premium and Cost-Sharing Subsidies to Individuals on Page 2 -- http://www.kff.org/healthreform/upload/finalhcr.pdf (http://www.kff.org/healthreform/upload/finalhcr.pdf)).
Tim
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Thanks Tim and Mr. Urban. I have been real hesitant about asking questions regarding this because I am extremely ignorant about the subject. I really do appreciate the help here.
Thanks again...
I'll go read this more in detail now...
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All I will say is if it's anything like what happened with Medicare Part D, we're all in for a roller coaster ride for a good 18 months at the minimum. While Med-D has/had its drawbacks with things like the doughnut hole, much of the messiness as far as HIV/AIDS went was how states chose to interface their ADAP programs with it. Before it began I went to a sparsely attended group meeting led by someone from the Ryan White planning council, met with a case manager, etc. and still got faulty advice that ended up costing me over $1,000 that I should not have paid, and of course I never saw that again.
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... Are the annual deductibles going to be eliminated? ...
(simple question -- not a simple answer :( )
No, but...
Some types of preventative care have to be covered without the deductible applying. In 2010. That's what this line in the Kaiser timeline means.
Require qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the U.S. Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women
If your medical plan is a group plan sponsored by a small employer then the deductible will be no more than $4000 for a family. But as Tim points out, you might be able to shop around for a policy that would be a better fit.
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The part of the reform that gives me some hope is the provision that destitute persons may be allowed to be covered by Medicaid. By that I mean people who make less than around $1,100/month, which would almost certainly be me if I returned home.
I wonder if anyone knows if destitute persons who are thus eligible for Medicaid would have their hiv medicines covered by that program, or if they would still need to utilize the ADAP program for those meds?
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People who are interested in getting into the details of a specific part of the health care reform bill may also find the summary prepared by the staff of the Joint Committee on Taxation helpful.
The joint committee on tax staf prepare a summary of any part of legislation that affects the tax code. It is "joint" because the same staff work on explaining and estimating the effects of tax bills in both the House and the Senate.
While they are "technical explanations" of the law, the staff always try to explain both the old law and the changes to it in terms a Congressperson can understand, or at least the staffer for that Congressperson who usually works on the issue can understand.
Many parts of the new law aren't related to taxes and so aren't covered by the summary. But many are.
For instance, the ability for some people to opt out of their employer plan and get a voucher to use in the Exchanges that Tim talked about is described in detail starting on page number 124 (pdf file page 128).
In other threads people have asked how the health spending account changes will work (see pp. 71-77).
It's not a good initial summary, but if there is just one detail you are interested in and it relates to the tax code, ... it is likely easier to understand than trying to follow the actual language of the Bills.
http://www.jct.gov/publications.html?func=startdown&id=3673
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The part of the reform that gives me some hope is the provision that destitute persons may be allowed to be covered by Medicaid. By that I mean people who make less than around $1,100/month, which would almost certainly be me if I returned home.
I wonder if anyone knows if destitute persons who are thus eligible for Medicaid would have their hiv medicines covered by that program, or if they would still need to utilize the ADAP program for those meds?
Yes, this is a huge improvement. Whereas Medicaid was originally an option for HIV-positive people with extremely limited incomes AND documented disability (i.e., an AIDS diagnosis) -- approximately 13 states had already done away with the disability requirement -- the new legislation basically entitles all people living with HIV in all 50 states who fall within 133 percent of the federal poverty line to Medicaid services. In fact, one thing that was really great about the reconciliation bill was its bumping up of Medicaid reimbursement payments to providers to the level paid by Medicare; in other words, we may see even more providers starting to accept HIV-positive individuals covered by Medicaid.
Your question, however, definitely falls into the fuzzy area. State Medicaid programs MUST provide the following to people living with HIV: inpatient and outpatient hospital services; physician and laboratory services; and long term care. Providing prescription drugs is not a requirement for states to receive federal funding, though all states currently do provide them (other "optional" services include dental care, clinic services, rehab services and case management).
I'm not reading anything in the legislation that mandates Medicaid must provide prescription drug benefits. Thus, it's not clear how states will restructure their programs as they prepare for the large increase in the number of people utilizing Medicaid-covered services. In other words, it's entirely possible that state Medicaid and ADAP programs may be forced to duke it out -- a massive headache, as pointed out by Miss Philicia. Then again, with the approval of the HCR legislation, pharmaceutical companies are now required to sell their drugs to Medicaid at prices that are lower than ever (e.g., the Medicaid drug rebate percentage for brand-name drugs was increased to 23.1 percent) -- hopefully, this will be an incentive for state Medicaid programs to extend its prescription drug coverage to all covered patients).
Tim
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Our limit right now is $2500, which we usually meet around the end of the fiscal year, just in time for it to reset.
This is why December is a very busy time for "elective" procedures. Our OR is extraordinarily busy in November/December as everyone gets things done before the deductible reset.
On a separate note, there appears to be an excise tax that got slipped in, that is going to be very difficult for poorer hospitals. All new equipment purchases will be subject to a 2.3% tax. This sounds fairly trivial until you consider most equipment has a life expectancy of 5 years.
Annual equipment budgets are in the 10's of millions of dollars for even mid size hospitals. A $250,000+ annual tax will translate into reduced employee benefits or positions.
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Tim, I asked Assur this question before and he explained to me that he has no answer to it right now, so I wanted to try my luck and ask you :
My insurance plan has a limit on pharmacy benefits, does the HCR eliminate this limit at once! which means I can still buy my medications even if I exceed the pharmacy limit?
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az:
Good question, though I'm not sure I have any more to add than Assurbanipal.
Over the next six months, the new legislation will tightly restrict the use of annual limits on insurance plans to ensure access to needed care. Technically, this should include prescription drug coverage. Beginning in 2014, the use of ANY annual limits would be prohibited for all new plans and grandfathered group health plans.
However, this is something of a wildcard, given that the pending restrictions -- again, those to be enacted in six months until the full law goes into effect four years from now -- on the insurance industry haven't yet been drafted. Kathleen Sebelius, Secretary of the Department of Health and Human Services (HHS), currently has the task of coming up with the restrictions and nobody is quite sure which direction she's headed in with respect to prescription drug coverage, as there doesn't appear to be any specific language in the legislation to guide her department.
Advocacy is still important here. My suggestion? Send Secretary Sebelius a letter, demanding that DHHS tightly restrict annual limits on prescription drug coverage and that annual caps on prescription drug coverage be included in the prohibition language to go into effect in 2014. There's certainly no harm in this, even if Secretary Sebelius is already considering this important addition.
Kathleen Sebelius
Secretary
U.S. Department of Health & Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
If, however, the directive from HHS doesn't include restrictions on annual prescription caps, you may have the option of shopping around for another policy -- whether you have an individual policy or a group policy -- via the Exchanges, provided that you meet certain income requirements.
Tim
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Thank you Tim,
Just to clarify about your suggestion that I should do shopping for another plan once I reach my limit, but wouldnt they deny me due to pre-existing condition that still applies till 2014?
I am covered by a group plan but it has a limit on the pharmacy benefits, and soon I will meet my limit , and since I already have an insurance I will be denied from the high risk option, but I will not make use of it, its kind of a funny situation!
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Thank you Tim,
Just to clarify about your suggestion that I should do shopping for another plan once I reach my limit, but wouldnt they deny me due to pre-existing condition that still applies till 2014?
Yes, they would if you apply before 2014.
I am covered by a group plan but it has a limit on the pharmacy benefits, and soon I will meet my limit , and since I already have an insurance I will be denied from the high risk option, but I will not make use of it, its kind of a funny situation!
The best advice I could offer is to try to work for a larger employer, with a big group, because they generally have much better insurance plans with lower premiums, copays and without such limits.
Even if you take a salary cut, the difference could be made up in benefits. When I switched jobs recently I didn't bother applying to startups or small companies for that reason. With 2 people on HAART on the company insurance, that would really wreak havoc in a small group.
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AZ:
I apologize if my last sentence was misleading. If prescription drug caps manage to escape the official end of annual insurance policy limits in 2014 -- and I can't imagine that private insurance companies will be permitted to maintain prescription drug caps when the legislation says that the use of any annual or lifetime limits will be prohibited from 2014 onward -- only then might you have the option of turning to the Exchanges, either with a federal subsidy or with the use of a voucher from your employer, depending on how affordable the plan is in relation to your income (and proximity to the federal poverty line). Then again, your employer will also likely turn to the Exchange that will eventually be set up for businesses, in an effort to get the best coverage for its employees and the best possible price.
You're right -- you do not qualify for the high-risk pools that will be set up this summer because you currently have an insurance policy.
Again, the hope here is that HHS will draft guidelines, to go in effect six months from now, that will restrict annual caps on prescription drug coverage.
Question: Have you reached out to the pharmaceutical companies that manufacture your ARVs about their patient-assistance programs (PAPs)? A simple call to the programs' "hotlines" will tell you whether or not you qualify -- the annual cap on your insurance coverage is certainly a qualifying factor; your annual income will also be taken into account. If you tell me which meds you're taking, I'll be happy to provide you with the relevant PAP number (there can be a lot of red tape to cut through with PAPs, if you qualify, so its best to start this process before your cap is reached). I might also suggest working with a social worker/case manager at your local AIDS service organization to help navigate this process.
Tim
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Does anyone know how this whole thing will affect Ryan White/ADAP? I know that a lot of states (mine included) are going to have to tighten the belt because of the lack of funding/general under funding of their respective programs. How will this be affected?
Sorry if this has been answered somewhere previously.
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Tokyo:
The signed health care reform legislation shouldn't have any impact on ADAP in the immediate future. Congress passed the Ryan White HIV/AIDS Treatment Extension Act in 2009, which extends funding for ADAP and other Ryan White programs in all fifty states for four another three and a half more years.
Nothing in the health care reform legislation alters this funding stream. This is somewhat unfortunate, really, given that ADAPs in many states simply don't have enough funding to immediately; waiting lists are becoming increasingly more common.
It will be interesting to see what happens when Ryan White is up for reauthorization again in 2013. With the expansion of Medicaid, the prohibition of pre-existing condition clauses and the setting up of the Exchanges, it's possible that people living with HIV will be "encouraged" to seek coverage through the mechanisms scheduled to be put into place over the next four years. Indeed, with increased federal funding for health care, along with the need for increased funding on the state level, its possible that Ryan White funding and qualification requirements will be scaled back considerably. HIV policy advocates, I'm sure, will be ready to cross this bridge when we come to it.
Tim
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Under the Wellness/Prevention, particularly where the coverage of preventive services are listed, it states the following:
Require qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A and B by the US Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolecents, and additional preventive care and screenings for women
Sorry I hit the post button before I finished typing. My question regarding the above is this: is labwork considered preventive services? And, if it is does it fall under preventive care rated A and B? From what I can tell the answer looks to be no, but I can't tell for sure.
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Skeebo:
The U.S. Preventive Service Task Force (USPSTF) recommendations are quite limited -- but important -- in that they dictate which screenings for various diseases must be covered by Medicaid and Medicare and should be covered by private insurance plans. Right now, the only HIV-related "A" rating in the eyes of USPSTF is HIV screening for adolescents and adults at increased risk for HIV infection, along with pregnant women.
Tim
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Thanks, Tim for this thread.
Does anyone know if states will still be allowed to impose an assets test (e.g., car,house,retirement saving) for Medicaid eligibility?
The reason I ask is because I currently have insurance through my job which works well, but I always have a nagging worry that if something happened to my health and I couldn't work, what would I do. Even in NY that allows childless adults to sign up for Medicaid (who meet certain income requirements), I know my retirement savings would disqualify me from Medicaid. My only option would likely be ADAP Plus, but even then my savings may be too high. I know a lot of us poz folk worry about this scenario.
Would I have to buy from the exchange and bleed my retirement if I suddenly became jobless -- or would I be able to sign up for Medicaid? I have scoured the web for answers, but could not find a clear answer. I like to be prepared for the worst-case-scenarios and hoping someone could shed light on this.
Thanks,
Mike
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Mike:
The reason I ask is because I currently have insurance through my job which works well, but I always have a nagging worry that if something happened to my health and I couldn't work, what would I do.
Well, assuming that you needed to stop work because of disability -- and qualified for Social Security Disability Insurance -- you would qualify for Medicare. Medicare currently covers an estimated 100,000 people living with HIV (approximately one fifth of people with HIV receiving care in the United States). Medicare qualifications are based, for the most part, on age or disability status. No matter how much loot you have in the bank, you'd be entitled to Medicare in the event of disability.
As for New York ADAP, liquid assets -- funds in your checking or savings account, funds in a money market account, certificate of deposit, mutual funds, stocks -- must be below $25,000. Your home is not considered a liquid asset, nor is your 401K or another retirement account, given that penalties apply if accessed.
Tim
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Thanks, Tim, for your response.
I guess my question revolves more around the mandate to have insurance (which I am not crazy about, but understand why it is necessary). If I couldn't work for a period of time (but didn't qualify for SSI as that is a pretty high threshold) or even if I lost my job and my income would essentially be zero, what would I do? Like I said, the current asset tests would make me ineligible for Medicaid and from your info on ADAP Plus I wouldn't qualify either. Would I have to Cobra my insurance (that would be expensive and I don't even know if Cobra will still exist)? If I have to have insurance, I wonder if I could buy into the exchange based on some asset formula or could get Medicaid in the interim. My meds being uninsured and/or paying Cobra would wipe out my savings fairly quick without insurance. My understanding is this law is to offer security and prevent bankruptcies, but I guess I am still not feeling the security until I learn more. Just trying to figure it out. I did just read that there will be no asset tests anymore with this new law -- but the source I didn't fully trust. I guess there are a lot of open questions still out there that need to be worked out by the states and Sebelius at HHS.
Thanks again for the info in your response!
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Question: Have you reached out to the pharmaceutical companies that manufacture your ARVs about their patient-assistance programs (PAPs)? A simple call to the programs' "hotlines" will tell you whether or not you qualify -- the annual cap on your insurance coverage is certainly a qualifying factor; your annual income will also be taken into account. If you tell me which meds you're taking, I'll be happy to provide you with the relevant PAP number (there can be a lot of red tape to cut through with PAPs, if you qualify, so its best to start this process before your cap is reached). I might also suggest working with a social worker/case manager at your local AIDS service organization to help navigate this process.
Tim
I am on Atripla, My Doctor provided me with a discount card but it only helps with my co-payment, I wonder if there is a way to cut on the actual price, When ever I raise this issue with my case worker , he suggests the ADAP, even though for many reasons I dont want to enroll it for certain reasons, in addition I wonder if the ADAP will still function with this health care reform, I am so frustrated with my insurance I pay high premium and just after I enrolled they send me this letter saying that my Meds are not included in the 2 million U$ year cap on Medical treatment! :-\
Thank you Tim for your help, I really hope to manage this issue, its not right that I have insurance and I pay for it , yet I cant use it for Meds , its absurd :(
Grateful for your help
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Thanks, Tim, for your response.
I guess my question revolves more around the mandate to have insurance (which I am not crazy about, but understand why it is necessary). If I couldn't work for a period of time (but didn't qualify for SSI as that is a pretty high threshold) or even if I lost my job and my income would essentially be zero, what would I do? Like I said, the current asset tests would make me ineligible for Medicaid and from your info on ADAP Plus I wouldn't qualify either. Would I have to Cobra my insurance (that would be expensive and I don't even know if Cobra will still exist)? If I have to have insurance, I wonder if I could buy into the exchange based on some asset formula or could get Medicaid in the interim. My meds being uninsured and/or paying Cobra would wipe out my savings fairly quick without insurance. My understanding is this law is to offer security and prevent bankruptcies, but I guess I am still not feeling the security until I learn more. Just trying to figure it out. I did just read that there will be no asset tests anymore with this new law -- but the source I didn't fully trust. I guess there are a lot of open questions still out there that need to be worked out by the states and Sebelius at HHS.
Thanks again for the info in your response!
If you lost your job and had no income you might find it much cheaper to buy a policy from the exchanges (assuming it is 2014 or later). That's because there will be premium assistance for low income individuals to buy premiums in the exchanges. Assistance would be available at up to 400% of FPL.
Typically, the exchange is set up to determine your eligibiliy for premium assistance based on the income you reported in your income tax filing two years before the year you buy insurance from the exchange. Then when you file your taxes, you will reconcile the assistance you got with what you should have gotten based on your actual income and pay the difference or get a refund.
But for people who have a sudden large (20%+) income loss or receive unemployment a special process will be set up so they can qualify immediately for the premium assistance, rather than looking back to income two years ago.
The premium assistance eligibility does not take assets into account. It is based on modified adjusted gross income for you and other members of your family plus any tax exempt interest.
The joint committee on tax document linked above has a precise and careful discussson of the affordability provisions for buying healthcare today vs. under the health care reform that on pp 10-17.
There will also be assistance for low income individuals with any co-payments and co-insurance. Eligibility is based on the same defintion of income. The best description of this program is in the Kaufman family foundation document Tim linked to listed as "Cost Sharing Subsidies". (The joint committee on tax explanation starts on p. 18 ...but is pretty opaque.)
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I am on Atripla, My Doctor provided me with a discount card but it only helps with my co-payment, I wonder if there is a way to cut on the actual price, When ever I raise this issue with my case worker , he suggests the ADAP, even though for many reasons I dont want to enroll it for certain reasons, in addition I wonder if the ADAP will still function with this health care reform, I am so frustrated with my insurance I pay high premium and just after I enrolled they send me this letter saying that my Meds are not included in the 2 million U$ year cap on Medical treatment! :-\
AZ:
Can you talk at all about your reservations regarding ADAP? If you can get ADAP to pick up the tab on your meds after you've met your annual prescription cap... well... that really is an amazing deal.
ADAP funding is secure at least through to 2013 (though programs in some states are currently experiencing serious budget problems, on account of increased demand due to the downturn in the economy and the upswing in unemployment). What happens when Ryan White is once again up for reauthorization in 2013 is anyone's guess, given the changes to health insurance regulations going into effect in 2014.
As for the Atripla programs, there are both co-pay assistance programs and patient assistance programs. The former, as its name implies, only covers pharmacy co-payments. The second, however, provides free Atripla to uninsured or under-insured -- it's not a stretch to suggest this applies to you -- individuals who meet certain financial criteria and simply don't have access to other public or private reimbursement options:
Atripla Patient Assistance Program
Phone: 1-866-290-4767
Perhaps you can have your case manager give the program a call to find out if you'd qualify? The program administrators might, however, suggest you go the ADAP route -- which brings you full circle.
Tim
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Not to be discouraging, but even when the law appears to be in black and white, it's apparently not in black and white.
This pissed me off to no end. Sadly, it won't be the last time we witness smug shirking of responsibility:
Coverage Now for Sick Children? Check Fine Print (http://www.nytimes.com/2010/03/29/health/policy/29health.html?ref=us) (New York Times, 29 March)
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Not to be discouraging, but even when the law appears to be in black and white, it's apparently not in black and white.
This pissed me off to no end. Sadly, it won't be the last time we witness smug shirking of responsibility:
Coverage Now for Sick Children? Check Fine Print (http://www.nytimes.com/2010/03/29/health/policy/29health.html?ref=us) (New York Times, 29 March)
meh
Don't be discouraged. That's what Technical Corrections are for. ..
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Typically, the exchange is set up to determine your eligibiliy for premium assistance based on the income you reported in your income tax filing two years before the year you buy insurance from the exchange. Then when you file your taxes, you will reconcile the assistance you got with what you should have gotten based on your actual income and pay the difference or get a refund.
But for people who have a sudden large (20%+) income loss or receive unemployment a special process will be set up so they can qualify immediately for the premium assistance, rather than looking back to income two years ago.
HUGE THANK :-[ YOU Assurbanipal! Exactly what I was looking for. Much appreciated (and puts my mind at ease).
Mike :)
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Well, this was a bit of a relief for me... Thanks, Tim!
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There've been a lot of questions on how the temporary high risk pools will work. The NYTimes Well Column doesn't have the final answers either, but does add some additional data comparing them to current high risk pools offered by the States:
Q. I don’t have health insurance. How soon will the new law help me?
The answer depends on your age and reasons for not having insurance. If you haven’t had insurance for six months, and you can’t afford or don’t qualify for insurance because of a pre-existing medical problem, you may be eligible for a new federal “high risk” pool to be offered by the end of June.
The cost of the monthly premiums hasn’t been announced, but the rates are to be based on a “standard population,” suggesting they will be based on a healthier group than typically used to calculate premiums for high-risk plans. On average, an enrollee won’t pay more than 35 percent of covered benefits, and annual out-of-pocket costs won’t be more than $5,950 for individuals and $11,900 for families. In addition, there are no lifetime limits — meaning the policy won’t be canceled if someone requires expensive medical treatment
Q. How many people can sign up for the new plan?
Until national health officials specify the premium costs and exactly what will or will not be covered, nobody knows how many people can sign up. The $5 billion set aside by Congress must last until 2014, when other options become available. By comparison, 35 states already spend a combined total of $2 billion annually on high-risk insurance pools that cover 200,000 people.
Q. How is the new federal pool different from what is already offered by state high-risk pools or Medicaid?
The federal plan is expected to offer more-affordable coverage than the existing state plans and will not impose the same income restrictions as Medicaid. State plans also typically impose high deductibles and premiums (some charge as much as $1,200 a month), and up to 12-month waiting periods before covering pre-existing health problems.
The experience of April and Steve Kohrherr of Afton, Va., shows how existing public plans fall short for many families. Their oldest son, Griffin, 6, has hemophilia, a severe bleeding disorder. His care, which has included brain surgery for a life-threatening bleed as well as twice-weekly infusions with a clotting drug, totals $500,000 or more a year.
The high cost of Griffin’s care would disqualify him from most state plans. Adding Griffin to the small group plan at the restaurant where Mr. Kohrherr works would have increased premiums for all the workers, making it unaffordable for everyone. Griffin now is covered by Medicaid, but he will lose the benefit if his family’s income exceeds about $40,000. Ms. Kohrherr works part time, but goes without insurance because the family of four cannot afford the $200 monthly cost to add her to her husband’s policy.
“If anybody was in my shoes and held their kid who was close to death, and if they had to worry about insurance at that moment, then they would never have been against this bill,” Ms. Kohrherr said. “All of the sudden I feel like I can think about my child’s future without worrying.”
http://www.nytimes.com/2010/03/30/health/30well.html?ref=health
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Another important benefit of the Patient Protection and Affordable Care Act of 2010 for PLWHIV:
Beginning in 2011, ADAP contributions will now count toward Medicare Part D's True Out of Pocket Spending Limit ("TrOOP").
Very good news.
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...
This pissed me off to no end. Sadly, it won't be the last time we witness smug shirking of responsibility:
Coverage Now for Sick Children? Check Fine Print (http://www.nytimes.com/2010/03/29/health/policy/29health.html?ref=us) (New York Times, 29 March)
I think (hope) Congress will, as mecch Assurbanipal said (well, he wrote "Technical Corrections," which I incorrectly assumed our Congress of leaders would fix) rectify this error.
A patently more disastrous and little known change will be taxation on INDOOR TANNING!! I urge all of you to join the spiraling protest movement against policies so clearly aimed at the melanin-deficient.
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Congress shmongress...
America's Health Insurance Plans to the rescue!
;)
“ Under pressure from the White House, health insurance companies said Tuesday that they would comply with rules to be issued soon by the Obama administration requiring them to cover children with pre-existing medical problems.
Health plans recognize the significant hardship that a family faces when they are unable to obtain coverage for a child with a pre-existing condition,” said Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group. Accordingly, she said, “we await and will fully comply with” the rules. "
http://www.nytimes.com/2010/03/31/health/policy/31health.html?ref=health
Tanning beds are bad for the New Orleans tourist industry. Tax them out of existence!
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I think (hope) Congress will, as mecch said, rectify this error.
A patently more disastrous and little known change will be taxation on INDOOR TANNING!! I urge all of you to join the spiraling protest movement against policies so clearly aimed at the melanin-deficient.
Is that really such a bad thing ?
Per wikipedia :
http://en.wikipedia.org/wiki/Tanning_bed
"Overexposure to ultraviolet radiation is known to cause cancer,[9] make skin age and wrinkle faster,[10] mutate DNA,[11] and reduce the immune system,[12] as well as other possible effects. There is no proof that these side effect are worse from tanning in a tanning bed or sunbed than from the Sun, due to the different intensity of the Sun and spectrum of the artificial light."
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Another important benefit of the Patient Protection and Affordable Care Act of 2010 for PLWHIV:
Beginning in 2011, ADAP contributions will now count toward Medicare Part D's True Out of Pocket Spending Limit ("TrOOP").
Very good news.
Does this mean that I can apply for Medicare rather than ADAP to cover my HIV Meds? can you please clarify on this issue, this sounds like a hope for many...
Please Tim explain this to me since its very important in case I wanted to apply for it !
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Does this mean that I can apply for Medicare rather than ADAP to cover my HIV Meds? can you please clarify on this issue, this sounds like a hope for many...
Please Tim explain this to me since its very important in case I wanted to apply for it !
You still need to be disabled in order to apply for Medicare. The eligibility for Medicare did not change (Medicaid eligibility will get easier though).
This provision has to do with the Medicare "donut hole" which the new health care bill is trying to close (in several ways)
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You still need to be disabled in order to apply for Medicare. The eligibility for Medicare did not change (Medicaid eligibility will get easier though).
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Does "disabled" mean as determined by SSA? I thought only those on SSD, SSI, or SSR were eligible for Medicare.
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Boo -- yes, Medicare is based on SSA criteria. One either needs to qualify for SSI (senior citizens) or SSDI (disabled;) to receive Medicare.
AZ -- As Assurbanipal explained, Part D prescription benefits are only for those covered by Medicare, which is based on previous employment (i.e., a history of paying into the system) and either disability (a bona fide AIDS diagnosis) or age (65 or older). Medicaid is different -- this is purely an economic qualification; starting in 2014, all Americans within 133 percent of the federal poverty level will qualify for Medicaid (until then, in many states, a person with HIV needs to meet both financial AND disability criteria [e.g., an AIDS diagnosis] to qualify for Medicaid).
Tim
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I thought this was the best place to add this. I heard this on MSNBC tonight and they were saying many don't know about this. It is regarding the mandate to buy insurance. According to MSNBC, the law says:
"In the case of any failure by a tax-payer to timely pay any penalty imposed by this section, such tax-payer shall not be subject to any criminal prosecution or penalty with respect to such failure."
So, they basically wrote in the law to not enforce the mandate. They were saying they don't want to publicize this in fear people won't buy. In a way, this seems like a good thing they did to not punish people. On the other hand, if healthy, younger people don't buy into it, I'm not sure how it will work. I know there's help for people who cannot afford to buy. I guess we'll see how it goes.
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Realistically the only people who won't be covered now are the self employed or people who contract work with many different employers.Since all employers will be required to insure their employees now the people falling through the cracks should be far fewer.
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Realistically the only people who won't be covered now are the self employed or people who contract work with many different employers.Since all employers will be required to insure their employees now the people falling through the cracks should be far fewer.
Sadly, this isn't exactly true. There really isn't much of an employer mandate. In short, companies with more than 50 employees must either provide health insurance or pay a fine of $2000 per worker each year if any employee received federal subsidies to purchase health insurance.
To entice businesses with fewer than 50 employees to purchase health insurance for their workers, a handful of incentives have been included in the legislation. By 2014, for example, states must set up Small Business Health Options Programs, or SHOP Exchanges. Basically, these will be established purchasing pools where small businesses can club together to buy insurance. Varying tax credits will also be available to some small companies, depending on their size and their average yearly wages.
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Ok one more question.
Is there a link or something to direct me to a chronological time line of how this will unfurl? I know that some stuff's beginning in 6 months, some stuff's beginning in 2014, but I'm just a little hazy as to what precisely. If not a link, just a ball park paraphrase'll do. :)
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Kaiser Family Foundation's HCR roll out timeline (http://www.kff.org/healthreform/8060.cfm)
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Perfect! Thanks.
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Yes Tim,... Thanks for that . Printed it out!
Ray
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Also, Treatment Access Expansion Project link: http://aidsconnect.net/content/blog/hivaids-and-health-care-reform-everything-you-need-know
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The Administration is starting to come out with some of the rules on how things will work. This week they issued guidance on how young people (under 26) can get coverage under their parents' policies.
http://www.hhs.gov/ociio/regulations/adult_child_faq.html
Some highlights:
-Your parents taxes won't go up if they add you. (And just like any other health insurance, you won't be taxed on benefits that are paid)
- You don't need to be financially dependent on your parents. You can be married and live thousands of miles away. The only reason they won't be able to add you is if you are over 25 or your employer offers you health insurance. (There's an exception to that second rule if your parents don't get their health insurance through an employer plan.)
-- You may be able to get your parents to sign you up now. Officially the new law applies to plan years starting after September 23. And since many plans use a calendar year that would mean January 1 for a lot of people. But the Administration has persuaded many insurers to start letting people in early (a list of insurance companies is included in the link). So if your parents buy their own insurance they may well be able to add you now. The Administration has started asking employers to let people in sooner too, but they haven't gotten a good response yet. So if your parents get insurance from their employers you may need to wait a while longer.
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The part of the bill that interests me is the provision that folks without insurance (me) and a preexisting condition (me again) will be able to acquire it through a high risk pool withen ninety days. It looks like there will be subsidies provided for folks on the lower end of the economic scale (definately me) to make it affordable. Also if I read the bill correctly, folks over a certain age and making under a certain amount will have the option to obtain medicaid. Not sure about that one. Anyway, I can't wait. I've been without insurance for a decade.
High risk pool with subsidies isn't going to be free.... so I wouldn't rush to get in the water til you make sure they aren't making soup!
I can afford insurance and the copays... but I do feel it.... it's not ideal, but better than nothing. I think the dust needs to settle first before we all figure out what's going on.
In the long run I anticipate Ryan White becoming insurance and co-pay subsidies. This will turn the ASO world on it's end which is a good thing. It will force customer service, reduce waste, and give patients a choice which is something that is long overdue for us.