Your Guide to Getting Health Insurance

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1 Your Guide to Getting Health Insurance

2 Getting Health Insurance: KEY QUESTIONS The following is a list of key questions and things to think about when selecting health insurance to best meet your needs under healthcare reform. Are you a U.S. citizen or documented resident? Can you prove it? If not, you can t buy health insurance in the Marketplace, and you do not qualify for Medicaid/ Medicare. For those who do not qualify, care may be available through the Ryan White program. If you are a U.S. citizen or legal resident, you must have health insurance. The following link will provide more information on immigration statuses that qualify for Marketplace coverage: Do you have Medicaid or Medicare? If yes, and your eligibility remains the same, you do not need to apply for new health insurance through Medicaid or Medicare. You cannot buy insurance in the Marketplace. Does your employer or your spouse s employer offer affordable health insurance (that costs less than 9.5% of your household income to cover yourself) with adequate benefits defined by the Affordable Care Act? If so, you are covered and are not required to buy insurance in the Marketplace. If not, you may be qualified for Medicaid or required to buy insurance in the Marketplace. What Marketplace should you use to find health insurance? Has your state set up its own Marketplace, or will you use the federal government s Marketplace? Visit to find out. What is your annual household income? Based on the number of people that live in your household and your annual income, you may be eligible for cost savings in the Marketplace. If you don t know your annual household income, you can find out by collecting your W-2 form, recent pay stubs, and your income tax return form. You can visit to find out about cost savings. How much can you spend on health insurance? Figure out how much you can afford to pay for health insurance. Think about your other monthly expenses such as food, transportation, and rent or mortgage payments.

3 Does your HIV provider participate in a health plan available to you? If your provider does not participate in the plan you select, you must pay additional costs to see that provider. This is called going out-of-network. Also, some health insurance plans consider HIV providers to be specialists. That means you may need to get a referral or other authorization from the insurer before seeing your provider. Some insurance plans may put limits on the number of visits you can make to a specialist. Think about these things when selecting your health insurance plan. If it is important to you to continue seeing your current health provider, try to choose a health insurance plan that your provider participates in. What are the limits for visits to your health provider s office? Will you have to share some of the costs? As a person living with HIV, it is important to see your health provider regularly to maintain regular care, get prescriptions for HIV and other medications, and keep a close watch on the disease and treatments. Make sure to ask if there are any limits on how many visits to your health provider are allowed each month or year. Also think about the cost-sharing requirements such as co-pays and deductibles, on office visits. What are the limits and cost-sharing requirements for lab tests? Will you have to share some of the costs? Regular laboratory tests are needed to monitor your health status and to properly adjust treatment as appropriate. For this reason, it is important to ask if the insurance plan you are thinking about places limits on the number of lab tests for HIV-related tests, including CD4, viral load, genotyping, and phenotyping. Also become familiar with cost-sharing requirements, such as co-pays and deductibles, on lab tests. Are your medications on the plan s prescription drug formulary? Make a list of all your medications so you can check to see if your particular drug treatment regimen is covered by the plans being offered. You should also find out about cost-sharing requirements such as co-pays or deductibles associated with your medications. Also learn about rules for prior authorizations or generic drug substitutions. Do you have other medical conditions? Will the insurance plan cover them? Many people living with HIV have other medical conditions. Get advice from your health professional about any other things you may need to think about when choosing a health insurance plan. Can you still receive support from the Ryan White Program/AIDS Drug Assistance Program (ADAP)? Depending on your state s Medicaid expansion status, you may need to access ADAP and Ryan White services to complete coverage offered by Marketplace plans, if you qualify. You can find a local Ryan White Program using the Health Resources and Service s Administration s locator tool:

4 Your Guide to Understanding C Do you have Medicaid or Medicare? Continue care through Medicaid or Medicare Are you a U.S. citizen or documented resident? Start here Does your employer (or spouse s employer) offer affordable health insurance (costs <9.5% of household income)? Has your state expanded Medicaid? Receive care through Ryan White Program Continue care through (spouse s) employer insurance TABLE 1 Federal Poverty Guidelines 2014/2015 Persons in Household 2014/2015 FPL for Continental U.S. Medicaid Eligibility (138% of FPL) 1 $11,670 $16,105 2 $15,730 $21,707 3 $19,790 $27,310 4 $23,850 $32,913 5 $27,910 $38,516 6 $31,970 $44,119 7 $36,030 $49,721 8 $40,090 $55,324 Source: Adapted from Obamacare Facts, Federal Poverty Guidelines 2014

5 overage Options Is your income <100% of FPL? (see Table 1) Receive care through Ryan White Program Receive care through the Marketplace Incomes >400% of FPL can use Marketplace, but won t get cost breaks (see Table 1) Is your income <138% of FPL? (see Table 1) Incomes % of FPL (or % for Medicaid expansion states) can use Marketplace and receive cost breaks (see Table 1) Receive care through Medicaid

6 Steps to Enroll Prepare: Discuss your health needs with your family and healthcare provider. Learn about the health insurance options in your state. Review your annual income, and determine what you can afford to spend on health insurance, before choosing a health insurance plan for you and your family. Act: Know the start and end dates for Open Enrollment Find the common application for the federal Marketplace at Review your annual income and household size to determine if you are eligible for tax credits, subsidies or other financial assistance. Evaluate your health needs, finances, and the benefits offered by each plan. Select your health insurance plan, taking into account out-of-pocket expenses including deductibles, co-insurance and co-payments. Key Information Marketplace Open Enrollment usually runs 3 months starting in October or November (visit You may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain Qualifying Life Events, which include, but are not limited to, moving to a new state, changes in income, and changes in family size (for example, a marriage, divorce, birth, or pregnancy). If you intend to enroll in a plan in the Marketplace, do you know how? (See Help to Enroll in Coverage on next page). Qualifying for Tax Credits and Lower Payments Are you eligible for cost savings such as tax credits or subsidies? Enrollment in Medicaid Determine if you are eligible for Medicaid when applying for health coverage in the Marketplace. Medicaid coverage can begin at any time. There is no enrollment period. In states that have expanded Medicaid, all individuals with income up to 138% of the Federal Poverty Level are eligible for the program. In states that have not taken up the expansion, Medicaid has varied income qualifications.

7 Help To Enroll in Coverage The U.S. Department of Health and Human Services (HHS) offers a single common application to determine eligibility for programs and assistance under healthcare reform. The process includes: Application for health coverage, which offers information about eligibility about buying health insurance through the Marketplace. The short form (Application for Health Coverage and Help Paying Costs), designed for individuals who know they are eligible to buy insurance through the Marketplace. The long form (Application for Health Coverage and Help Paying Costs), designed for families who know that they are eligible to buy health insurance through the Marketplace. Many systems have been set up to assist in enrollment nationwide. Patient Navigators and Certified Enrollment Counselors are available in every state to help you enroll in either health insurance plans offered in the Marketplaces or in Medicaid in your state. Where to Enroll You may enroll for coverage online, by phone, and through in-person enrollment. You may apply either through the Marketplaces (in your state s Marketplace or the federal Marketplace if your state chose not to create its own Marketplace) or through your state Medicaid program. Many Community Health Centers also provide in-person enrollment assistance. The application helps identify eligibility for either Medicaid or for Qualified Health Plan coverage, and premium tax credits.

8 Distributed by: Janssen Therapeutics, Division of Janssen Products, LP, Titusville, NJ Janssen Therapeutics, Division of Janssen Products, LP /

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