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Addressing the Cost of Care

Paying for HIV Care

HIV care and treatment involves a commitment to ongoing visits with your health care provider, tests to monitor your health status, and medications.

These things are important because with the proper care and treatment, you can reduce your viral load, protect your health, enjoy a long and healthy life, and reduce the potential of transmitting the virus to others.

But you might have concerns about how to pay for this. There are resources that can help you pay for the care you need.

Private insurance

If you have private health insurance through your employer (or have purchased it yourself), your insurance company may pay for your HIV care. But it’s important to find out what your provider will (and won’t) cover.

Finding Private Insurance—If you are seeking private health insurance, HealthCare.gov’s insurance and coverage finder tool can help you find the health insurance best suited to your needs and compare private insurance policies as well as see if you qualify for public programs. HealthCare.gov also explains your health insurance options under the Affordable Care Act.

The Health Insurance Marketplace—When key parts of the Affordable Care Act take effect in 2014, there will be a new way to get health coverage: the Health Insurance Marketplace. This is the portal where eligible consumers can shop for qualified health plans. Every state will have a Health Insurance Marketplace, but each state can choose how it will operate. States can create and run their own Marketplaces, or have a Marketplace supported by the Department of Health and Human Services (HHS). States may also choose to partner with HHS to run some functions of their Marketplace.

Every health insurance plan in the new Marketplace will offer comprehensive coverage, from doctors to medications to hospital visits. Through the Marketplace, you will be able to compare all your coverage options based on price, benefits, quality, and other features that may be important to you. Visit HealthCare.gov to get information about your state Marketplace and to sign up for updates on Marketplace enrollment, beginning in October 2013.

Keeping Your Health Insurance—In addition to the Affordable Care Act, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) helps people living with HIV/AIDS keep their health insurance. Part of the law protects people when they lose or change jobs by offering insurance "portability" to qualifying people. The law also sets guidelines to keep people's medical information private. Read about insurance and your legal rights.

Federal resources

If you do not have private health insurance—or you need help because your insurance doesn’t pay for the HIV care and treatment you need—there are Federal resources that may help you.

Getting Help—Figuring out which programs and services you qualify for can be confusing. But don’t worry! There are case managers and benefits counselors who can help you. They know what services are available and can help you get care. Their services are free. You can find one near you by going to the HIV Testing and Care Services Locator. If you don’t have regular access to the Internet, toll-free State HIV/AIDS Hotlines will help put you in touch with agencies that can determine if you are eligible and help you get care.

Here are Federal resources that are available:

  • Medicaid—A state and Federal partnership, Medicaid provides coverage for people with lower incomes, older people, people with disabilities, and some families and children. It accounts for approximately half of Federal spending on HIV/AIDS care in the U.S. and is a critical source of coverage for many people living with HIV/AIDS. Medicaid provides financial assistance for outpatient and inpatient care, as well as for prescription drugs for people who are eligible. The eligibility rules for Medicaid are different for each state, but most states offer coverage for adults with children at some income level. In addition, starting in 2014, states will have the option, which is fully Federally funded for the first three years, to generally include individuals with income below 133% of the Federal poverty line ($14,400 for an individual and $29,300 for a family of 4), including single adults without children who were previously not generally eligible for Medicaid. As a result, in many states, a person living with HIV who meets this income threshold will no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. To learn more about your state Medicaid program and other options available to you, use HealthCare.gov’s insurance and coverage finder or visit Medicaid.gov.

  • The Ryan White HIV/AIDS Program—The Ryan White HIV/AIDS Program is a Federal program that provides health care, medications, and other health-related services to people living with HIV/AIDS who cannot otherwise pay for it. To be eligible, you must:

    • Be diagnosed with HIV or AIDS.
    • Have an income too low to pay for care.
    • Have no health insurance or not enough insurance to pay for the care you need.
    In some cases, your family members can receive services through a Ryan White program focused on women, infants, children, and youth, even if they are not diagnosed with HIV/AIDS. The program also offers dental services for people living with HIV/AIDS and an AIDS Drug Assistance Program (ADAP).

  • The Health Center Program—There are more than 8,000 community-based health centers across the country, annually serving more than 20 million Americans who have limited access to health care. These health centers provide HIV testing and other services to people living with HIV/AIDS, with fees adjusted based on a person’s ability to pay. Some patients receive services directly at the health center itself, while others are referred to an HIV specialist in the community. Major investments in the network of community health centers over the past several years have created more opportunities for HIV care delivery. You can find a health center near you by going to the HIV Testing and Care Services Locator

  • Medicare—Medicare is health insurance for people age 65 or older, people under 65 with certain disabilities, and people of all ages with End-Stage Renal Disease. Medicare coverage for eligible individuals includes outpatient care, prescription drugs, and inpatient hospital care. For more information and to find out if you are eligible, visit Medicare.gov. You can also read more about Medicare and how the Affordable Care Act improves benefits and expands choices by visiting HealthCare.gov

  • Federal Programs for Women and Children—There are several Federal programs to help low-income women and children access healthcare. The Children’s Health Insurance Program (CHIP) provides low-cost health insurance coverage for children in families who earn too much income to qualify for Medicaid coverage but who can’t afford to purchase private health insurance. Title V of the Social Security Act (SSA) serves low-income women and children with limited access to health care, including children with special needs. To find information about women and children’s coverage programs in your state and options available to you, use HealthCare.gov’s insurance and coverage finder. You can also read about how the Affordable Care Act helps women and families with children.

  • American Indian and Alaska Native Programs—The Indian Health Service (IHS) provides health care services—including HIV services—for members and descendents of federally-recognized American Indian and Alaska Native Tribes. For more information, go to http://www.ihs.gov.

  • Veterans Programs—The Veterans Administration (VA) is the largest single provider of medical care to people living with HIV in the U.S., supporting over 24,000 Veterans living with HIV. If you are eligible, you may be able to receive HIV care through the Veterans Health Administration. VA offers an online benefits website where Wounded Warriors, Veterans, Service Members, their families, and their caregivers can learn about compensation, financial assistance, health care, housing, and other VA benefits. The site includes a health-benefits eligibility calculator you can use to assess whether you qualify for VA health care benefits.

Non-Federal resources

Patient Assistance Programs and the Common Patient Assistance Program Application—Patient Assistance Programs (PAPs) are programs administered by private drug companies and foundations to offer free or reduced-cost HIV drugs to people with low-incomes who do not qualify for any other insurance or assistance programs. Different PAPs have different eligibility criteria, often based on a person’s poverty level.

HHS, working collaboratively with seven pharmaceutical companies, the National Alliance of State and Territorial AIDS Directors (NASTAD), and community stakeholders, has developed a common patient assistance program application that can be used by patients and providers. This form is a one-stop shop that collects the necessary information required of PAP applicants. Prior to the development of the common application form, patients and their advocates had to fill out different sets of paperwork to apply for assistance from each company. This was a time-consuming and burdensome process. The new streamlined application has the potential to provide faster, easier access to live-saving medications.

Company PAPs that are accepting the common application form include:  Abbott Laboratories, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Inc., Johnson & Johnson (Janssen Therapeutics), Merck and ViiV Healthcare.

Frequently Asked Questions

If I have private insurance, can I access services like Medicare, Medicaid, and ADAP to help pay for my HIV care?

In general, if you have private insurance and/or health insurance provided by your employer, you will not be eligible for State or Federal benefits. There may be exceptions, however. To find out if you are eligible, use HealthCare.gov’s insurance and coverage finder tool.  

Last revised: 04/25/2013