Information for Individuals With HIV or AIDS

This page provides basic information to people living with HIV or AIDS who enroll in a health insurance plan through Covered California.

Choosing the right health insurance plan is important. Health insurance plans sold through Covered California have standard benefits, including prescription drug coverage, doctor's visits, hospitalization, labs, and mental health and substance abuse services, which help consumers compare health insurance options. It is important to review each plan's price, provider network, "Summary of Benefits and Coverage," as well as more detailed coverage descriptions, to find the plan that best suits consumers’ needs. A consumer should consider all of the expected costs when picking a health insurance plan. Costs may include monthly premiums and out-of-pocket costs such as copayments, coinsurance and deductibles. The out-of-pocket maximum is the most a consumer could have to pay out of pocket for medical expenses during the year. Keep in mind that out-of-pocket maximums differ depending on a consumer’s income and which metal tier of plan selected (Platinum, Gold, Silver or Bronze).

The metal-tier system is based upon how much individuals must contribute toward their health care upfront as premium versus out-of-pocket costs when using services. A Bronze-level plan may have a lower monthly premium than a Platinum plan, but it has higher deductibles, copays and other out-of-pocket expenses. It is important to figure out which level of health insurance plan best suits consumers’ health care needs.

Consumers may be eligible to get help paying the monthly premium if their income is over 138 percent and up to 400 percent of the federal poverty level (FPL). If consumers are eligible for financial assistance, their monthly premiums will be lower.

Consumers may be eligible for even more financial help paying out-of-pocket costs if their income is over 138 percent and up to 250 percent of the FPL. These additional cost-sharing reductions will lower their out-of-pocket health care costs, such as copays and deductibles. This additional financial assistance is only available if consumers select a Silver plan and is known as an Enhanced Silver plan. Depending on each consumer’s situation, costs may be lower with a Platinum plan than with an Enhanced Silver plan, so consumers should look closely at their options.

If a consumer would like to continue seeing the same doctor they see now or continue using the same pharmacy as they use now, contact the health insurance company to find out which doctors and pharmacies are in the health insurance plan's network. Consumers can also ask their doctors or pharmacy about which health insurance plan networks they are in. Be sure to check the health insurance companies' lists of covered medications, known as drug formularies, to make sure any drugs currently taken are covered by the plan selected. To find the health insurance companies' drug formularies, contact each health insurance company directly or contact the California Department of Public Health's Office of AIDS. It is important to remember that plans' drug formularies can change at any time and the plan will have the most up-to-date formulary.

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% 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.

More Information

For questions about enrolling in health coverage, contact Covered California at (800) 300-1506 or visit www.CoveredCA.com.

For questions or additional information about drug or premium assistance programs for eligible individuals living with HIV or AIDS, contact the California Department of Public Health's Office of AIDS at (916) 449-5900 and ask to speak to someone in ADAP or OA-HIPP, or visit their website.

Links to Websites Mentioned on This Page

ADAP Pharmacy Benefits Manager

Antiretroviral (ARV) drugs available on the ADAP formulary, along with those available through Covered California health insurance plans (PDF)

Office of AIDS' Health Insurance Premium Payment (OA-HIPP) program enrollment

Qualifying circumstances for continuity of care

Health insurance plans regulated by the Department of Managed Health Care

California Department of Public Health's Office of AIDS