Slow down: People with HIV don’t need to enroll October 1

| September 11, 2013

keep-calm-and-go-slow-4Consumers can start enrolling in marketplaces and in Medicaid (in some states) starting October 1.  But people with HIV have special circumstances – and many should wait to enroll.  Here’s why.

1. We don’t know what marketplace plans look like.

Very few states have released complete information on the benefits that plans will provide and exactly how much they will cost. (California  is one of the few.)  In the 35 states  where the federal government will run the marketplace, plan details won’t be available until October 1.

Of course, we want to make sure people with HIV enroll in a plan that includes their current provider and covers their meds, all at a reasonable cost.  We also want to know which plans AIDS Drug Assistance Programs (ADAPs) can coordinate with (more about this below).  It’s impossible to figure out those details without seeing the plans.

ACTION STEP: To help you figure out which plans will work for people with HIV, the Center for Health Law and Policy Innovation of Harvard Law School has created a health plan assessment tool.   Start talking with other HIV service providers in your area to figure out how you can divide up the work.

2. We don’t know what ADAPs will do (and some ADAPs don’t either).

The second reason people with HIV should wait to enroll in the marketplaces is that most ADAPs won’t be ready.  Many state ADAPs can pay premiums and out-of-pocket costs for HIV medications.  But it’s not clear in all states exactly what role ADAPs will play with new marketplaces.  Here are some of the issues ADAPs are working out:

  • ADAP staff haven’t reviewed the marketplace plans yet either.  All sorts of magic has to happen behind the scenes for ADAPs to help with premiums and co-pays, but ADAP staff need the plan details to know what will work.  They’re in the same boat we are, waiting for plans to be released October 1. In states where ADAPs can coordinate with marketplace plans, it may take up to a few weeks for ADAPs to release a list of coordinating plans.  Consumers can’t switch marketplace plans once they have enrolled, so it will be worth the wait.
  • Politics is getting in the way.  Some governors are opposed to the Affordable Care Act (no news there) and have forbidden state agencies to spend any resources on health reform implementation, or even talk about it.  This goes for ADAPs too.  Some have been prohibited from releasing any guidance to the community on how ADAPs will coordinate with health reform plans.
  • The wheels of state government turn slowly.  ADAPs that have insurance coordination programs may need to beef up their systems for health reform, which could mean reallocating funds or putting in place new or expanded contracts.  ADAPs that have never had insurance purchase programs face the challenge of building all-new programs at a time of dwindling resources.

ACTION STEPS:  Ask your state how its ADAP will coordinate with new health reform programs.  Questions to ask are: Will ADAP coordinate with new marketplace plans?  If so, when will they announce which ones?  Will the state be able to pay premiums?  How much can the state pay?  Can the state pay co-pays and other out-of-pocket costs for HIV medications?

If you don’t get an answer, band together with other advocates to develop a strategy to find out what ADAP plans to do.  Remember that in the current political environment, a behind-the-scenes strategy may be more effective at this moment in some states.

So while you’re taking care of those two items, start Medicaid enrollment October 1 (if your state is expanding)

In states that are expanding Medicaid, start enrolling clients on October 1. Check out these screening tools  to help you identify clients who might be eligible for Medicaid or the marketplace.   Note that even in states that are expanding, Medicaid enrollment may be delayed because computer systems aren’t ready, or the start day of coverage may be after January 1.

Oh – one more thing.  Many HIV health care providers don’t know what plan (if any) they are enrolled in.  That’s another good reason to wait to enroll.  People with HIV should check with providers before enrolling to see what networks they are in.

We want to hear from you!  Was this blog post helpful? What questions do you have?  Email us.



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