People With HIV Or AIDS

Additional Drug and Premium Payment Assistance Programs

Consumers may be able to get help paying for their HIV or AIDS medications. The AIDS Drug Assistance Program (ADAP) within the California Department of Public Health helps ensure that eligible individuals living with HIV or AIDS who are uninsured and underinsured have access to life-saving HIV medications. An individual with a modified adjusted gross income (MAGI) up to 500 percent federal poverty level may qualify for ADAP. For ADAP eligibility information, including where to go to enroll, drug formulary lists and participating ADAP pharmacies and locations, please call (844) 421-7050.

ADAP can provide drug deductible and copayment assistance for drugs on the ADAP formulary. In order for ADAP to assist a consumer with these drug costs, their health insurance plan’s pharmacy must also be a participating ADAP pharmacy. A list of the antiretroviral (ARV) drugs that are available on the ADAP formulary, along with those available through the Covered California health insurance plans, is available as a downloadable PDF.

Qualified individuals enrolled in ADAP can also receive help paying Covered California monthly premiums through the Office of AIDS’ Health Insurance Premium Payment (OA-HIPP) program. Individuals enrolled in OA-HIPP may also get assistance with outpatient medical out of pocket costs.

If a consumer and a third party, such as OA-HIPP, both paid the consumer’s premium for the same month, they may contact the health insurance company and request a refund. They may also contact the health insurance company for any other issues relating to premium payments.

Keeping the Same Doctor for Services

“Continuity of care” is the continuation of a care plan for a limited amount of time despite switching to a new health insurance plan or experiencing a change in the provider, hospital or pharmacy network of a consumer’s health insurance plan. Individuals in this situation may want to continue health care services with their previous doctor or hospital. To receive continuity-of-care services, consumers must contact their new health plan and request continuity of care. A consumer’s doctor or hospital also must agree to keep them as a patient.

Only people with certain types of health problems or conditions can receive continuity of care. HIV and AIDS may qualify as “serious chronic conditions,” which would allow for a maximum of 12 months of continuity of care. A complete list of qualifying circumstances is available from the Department of Managed Health Care website.

If a consumer thinks they might be eligible for continuity of care, they should contact their current Covered California health insurance plan and request it. Ultimately, a continuity-of-care request is between the consumer’s current health insurance plan and their previous doctor or hospital. If their health insurance plan denies their request for continuity of care or delays giving them an answer, they can file a formal grievance (also known as a complaint or appeal) with the health insurance company. If a consumer’s health insurance company does not resolve their grievance/complaint/appeal to their satisfaction, contact the California Department of Managed Health Care’s Help Center at (888) 466-2219 for help. If a consumer’s Covered California health insurance plan is a Health Net PPO plan, contact the California Department of Insurance at (800) 927-HELP (4357).

Note: Covered California does not decide on continuity-of-care requests. Additional continuity-of-care information related to health insurance plans regulated by the Department of Managed Health Care can be found on the Department of Managed Health Care website. For free, confidential and local help with grievance process, contact the Health Consumer Alliance at (888) 804-3536 or visit www.healthconsumer.org.

Keeping the Same Drugs and Medications

If a consumer enrolls in a Covered California health insurance plan, their new plan may cover any drugs and medications they were taking before enrolling, but this depends on many factors. Also, the list of drugs (also known as the formulary) that Covered California health plans cover may periodically change. If a consumer has questions or concerns about their access to a particular medication, they should first contact their health insurance plan directly and request that medication. If their request is denied, they should file a formal grievance (also known as a complaint or appeal) with the health insurance plan. If their health insurance plan does not resolve their grievance/complaint/appeal to their satisfaction, contact the California Department of Managed Health Care’s Help Center at (888) 466-2219 for help. If a consumer’s Covered California health insurance plan is a Health Net PPO plan, contact the California Department of Insurance at (800) 927-HELP (4357). If they need medications urgently and their health insurance plan is not responding, consumers can also contact the Department of Managed Health Care or the California Department of Insurance for help.

For free, confidential and local help with the grievance process, contact the Health Consumer Alliance at (888) 804-3536 or visit www.healthconsumer.org.

Additional Services and Resources

Individuals living with HIV and AIDS may be eligible for additional services funded through the Ryan White Program, including case management, nutritional support, transportation and free legal services. Contact the California Department of Public Health’s Office of AIDS at (916) 449-5900 for more information.

Free, Confidential and Local Assistance Is Available

Working through payment issues, medication requests, continuity of care and other issues can be difficult. Covered California has made available free, confidential and local assistance to all enrollees. The Health Consumer Alliance can help enrollees work with their health insurance company and, if necessary, work with health insurance regulators. Call (888) 804-3536 or visit www.healthconsumer.org.