AIDS Care Group

Medical, Dental, and Social Services in Delaware County, PA

AIDS Service Organization Blog

PA’s Insurance Update

Kevin Moore, PsyD talks about PA’s Insurance Update in his presentation he did for our medical offices.
Healthy PA is the new Medicaid
•The 14 current eligibility categories are being reduced to 3 categories as of Jan 1
–Low Risk “Healthy”
–High Risk “Healthy Plus”
–Private Coverage Option (PCO)
•Notification letters have been mailed to all Medicaid recipients
•Everyone will receive new Medicaid cards
Healthy PA will expand the number of people who can be covered
•The newly eligible earn $11,670 to $16,104 for a single adult (add $4,060 per each dependent)
•This is estimated to be 600,000 Pennsylvanians
•They will not pay a monthly premium in 2015
•It is only in this sense that Healthy PA is “Medicaid expansion”- it expands the number of people covered
Healthy PA is Medicaid reduction
•“Healthy” plans limits annual benefits to $350  for lab work, 2 inpatient admits, 30 D&A outpatient visits, 30 MH outpatient visits, 4 specialist visits, 6 radiology tests, and yet-to-be seen pharmacy formulary changes.
•“Healthy plus” plans limits annual benefits to $450 for lab work, 3 inpatient admits, 60 D&A outpatient visits, 60 MH outpatients visits, 8 radiology tests, and yet-to-be seen formulary.
What is the low/high risk distinction?
•Enrollment is designed to put as many people into low risk “Healthy” plans as possible
•Adults will get “Healthy Plus” if they
–Receive MA in an SSI related category
•Healthy Horizons
•Nursing Home MA
•Home and Community Based Services
•MAWD (more on this later)
–Over 65
–“Medically frail”
What is “Medically Frail”?

Serious and complex medical conditions

–HIV/AIDS or immune deficiency
–On a ventilator or dialysis or hospice
–Chemo/radiation therapy for cancer
–Sickle cell or hemophilia
–Cystic fibrosis or Gaucher’s disease
–Resident of a LTC facility or public/private ICF
–Or 2+ hospital admits in 12 mo AND 3+ ER visits in 6 mo AND 4+ prescriptions per month
•Physical disability such as MS or paraplegia
•Disability designation by Social Security
•Certain mental disorders: major depression, bipolar disorder, schizophrenia spectrum (including schizoaffective, delusional disorder, and “psychotic disorder”), anxiety disorder (OCD, PTSD, “severe panic disorder”)
•Chronic substance use disorder
•Intellectual or developmental disability
How is the low/high risk distinction made?
•By a medical review board
•By a claims review board
•By completing Employability Assessment Form (PA 1663) with box 1 or 2 checked
•By completing a “health screening form”
–Form not released- “just questions that are asked”
–Only available through phone or COMPASS (on-line), not available at County Assistance Offices
–November 26th deadline!
What about the PCO option?
•PCO will be run through new PCO marketplace, i.e. not existing Medicaid HMOs nor Health Insurance Marketplace
•This will likely be even more problematic than was last year
•Plans aren’t available yet but Keystone First, Aetna, and United Health Care speculated to all have plans
•Enrollment will be on-going through 2015, which is good: no end to open enrollment
PCO benefits
•On the one hand, PCO has fewer limitations than low or high risk: only limits on D&A, MH
•On the other hand, if you are “medically frail” you get “Healthy Plus” anyway!
•Need to apply through new PCO marketplace, even though end up in the same place
•PCO marketplace site not ready although is running and presumably where it will be hosted
Recommendation for Action

To maximize the chance to get Medicaid patients enrolled in “Healthy Plus,” I recommend:

•Proactively inform your patients immediately
•Prompt them to open their mail and make sure they will be enrolled into “Healthy Plus”
•If not assigned to “Healthy Plus,” complete a “health screening” through COMPASS ( or phone number (866-550-4355) before Nov 26th
Medical Assistance for Workers with Disabilities (MAWD)
•MAWD survived being cut this year because it is a great program, although it will be less great when it becomes the “Healthy Plus” plan
• You are eligible for initial enrollment up to $29,175 (250% Federal Poverty Level) regardless of how much you work.
•Typical premium about $50/month, but no co-pays, deductibles, or co-insurance- only “Healthy Plus” service limits
•ACA is inferior to MAWD in that it has higher monthly premiums, deductibles, co-insurance, and co-pays even if thought it does not have the services limits.
•Therefore if you qualify for MAWD, I recommend you take it.  If not, ACA is the best option.
•Reminder that there is a tax penalty in 2015 of 2% of income to a maximum of $325 for not having insurance.
I recommend the following:
•If under $11,670, try to get “Healthy Plus” through COMPASS
•If under $16,104, try to get PCO and thus “Healthy Plus” through
•If under $29,175, try to get MAWD and thus “Healthy Plus” through COMPASS
•If under $46,680, buy a “Silver” ACA plan through
“Silver” ACA Plans in the Health Insurance Marketplace
•“Silver” plans have the premium tax credit and the cost-sharing subsidies.  Educate patients not to bother looking at other plans unless above $46,680 as it averages half the cost.
•Generally cover 70% of costs with different plans varying around how much premium, deductible, co-insurance, and co-pays.
•I recommend IBX plans because they have an open panel approach (credentials any provider who asks) while Aetna has a closed panel (you can only see their providers)
•Advantage Plans (Part C plans) are predatory entities with an aggressive sales force in PA
•New data shows that Advantage Plans are inferior for patients with complex medical needs
•Pros are simpler cost-sharing arrangements and some perks like gym memberships
•Cons are service restrictions that are nearly always problematic for anyone with a chronic care condition and premiums average the same as adding together Part B and Part D premiums
Assist Patients with Medicare
•Can only change plans once a year
•Open Enrollment ends December 7th
•I recommend advising people to drop Advantage Plans and enroll in Part B/ “straight Medicare” and Part D plans
•I’ve seen patients with Part B who didn’t know they could enroll in Part D -> education
•I’ve seen patients with Medicare who are dual eligible but not enrolled in Medicaid -> education

When are you done with psychotherapy?

It had been a total of three years that I had been in therapy when an acquaintance declared to me that, after her six sessions of therapy, she was cured of all her mental health issues and did not need to go to therapy again. Part of me wondered what was wrong with me that after a second course of treatment with a therapist and a total of three years in therapy, I still had a list of things that I knew I needed to work on. Another part of me remembered a time when I thought therapy had fixed all my problems.  I reminded myself that I had set myself for failure at that time.

The first time I went to therapy I received a diagnosis of an anxiety disorder. At that time, insurances could still cap how many therapy sessions per year you could have. My insurance capped my sessions at 22 per year. When my 22 sessions were over, I believed that I would never have to go to therapy again because I had gained all the tools I needed to live a mentally healthy life.  The artificial boundary created by the insurance company had helped convinced me that I was done.   I was very surprised when, 18 months later, I was back in therapy for a different diagnosis.

Based on my experience as a patient, I would make the following recommendation on how to decide when to end therapy:

  1. Begin therapy with time limited goals on which you want to work on. As an example, people going to therapy for panic attacks could decide some of their goals can be mastering techniques to calm down during an attack, what their triggers are, and how to learn to deal with those triggers.

  2. While in therapy, focus on the original issue; if anything else comes up, “car park” those issues unless they are pertinent to the original problem. Remember it is okay to go back to a specific issue later.

  3. If you’ve completed the issues you’ve “car parked”, ask your therapist if he or she thinks that you are ready to be done. Your therapist has your best interest at heart and will let you know if he or she believes you are ready to be done with therapy.

  4. Ask yourself if you believe the problem you went into therapy for has become manageable to you. Do you think that you can comfortably control life’s difficulties on your own? If you can do these things, it might be time to finish with therapy.

  5. Just because you have worked out these issues, understand that other issues might arise and it is okay for you to go back to therapy. As humans, we never finish growing and we sometimes need help during a growth spurt, so know it is okay to go back to therapy.

The Mental Health Scarlet Letter Part 3

A third story in this series on stigma is about Megan, a college student. Megan’s story interested me because she, like me came from an immigrant family who has different views on mental health than Americans. When she tried to talk to her friends and family about her depression, they told her it was all in her head. She was told she needed to get over it and that she was being over-dramatic in order to get attention. She described her depression as a dark cloud that took over all of her and got worse due to her family and friends not understanding it.

Mental health stigma can come from so many places in our society. Stigma can come from news media that are unsure how to talk about mental illness. It can come from our own friends and family who do not know what those of us with mental health issues are going through because they have never experienced it themselves. It can come from our church congregation who is unsure how to deal with such an illness. It can also come from co-workers or employers who question how someone with mental illness can fit in the work place or if their productivity will go down due the employee’s mental issues.

How do I, one person, break down the barriers of stigma?I have come to realize that to break down the stigma of my depression I cannot keep it a secret. I talk about my mental health issues openly. If you are not keeping your mental status a secret, it will no longer be something people are trying to figure out. Talk about what your condition does to you. After several years of explaining my depression and panic attacks to my mom, she finally has begun to understand that I am not crazy but that my body works differently than hers or others. My supervisor and I made a plan so I could see my therapist every week and still carry my portion of the work. I remember being told that if I were myself people would love me. I have learned that there was truth in this childhood phrase. There will always be those that do not understand mental illness but if you surround yourself with those who are willing to learn about your struggles, life becomes better and a little easier.

The Mental Health Scarlet Letter Part 2

The first story about mental health stigma is from a woman I’ll call Cheryl, a mother of six children, a devout member of her church, who has been married for fifteen years. When I met Cheryl, I was fascinated by how vocal she was about her depression and what she does to make it better. She’s a member of a church that openly talks about mental health issues and how there should be no stigma for those in her church who suffer mental health issues. Yet, Cheryl says her experience was not one of being stigma free. She talks about being ignored by other members in her congregation and not being asked to participate in church activities because of her depression. She related to me how stigma she felt made her depression worse.  By speaking out about her experiences, she advocates for herself and others.  She feels that speaking out directly makes her depression better.

Our second story is about Dave a single father of four, who suffered from chronic depression since high school. When I asked him if he had ever suffered stigma due to his illness he immediately replied he had been lucky to never have suffered any stigma.  He does not remember ever being told negative things about having a mental illness.  He also related throughout his career he has been very careful about what he tells his supervisors about his illness and his constant doctors’ visits. Why has he been so careful?  A previous manager eventually fired Dave after he explained his frequent doctor’s visits were due to treat his mental illness.  I would argue that Dave has suffered stigma, although he hasn’t endured the bad metaphors of mental illness that I’ve heard throughout my life.

Both Cheryl and Dave give us examples of stigma in its various forms.  The next blog will give another variation and share some thoughts on breaking down stigma.

The Mental Health Scarlet Letter

“If I got rid of my demons, I’d lose my angels.”
― Tennessee WilliamsConversations with Tennessee Williams

Often, people use metaphors when talking about mental illness, usually with mental illness as a mythical battle between good and evil.  While some metaphors might be necessary, I feel I’ve been hurt by bad metaphors.  When we use bad metaphors for mental illness we are making it harder for others to accept mental illness.

I’m referring to some of the language my family has used to talk about my mental illness and that of other family members.  When family members witnessed me crying inexplicably at a young age, they told me that the devil had gotten to me.  I later learned I was depressed.  When talking about other family members, depression was described either as “crazy” or an unwillingness to accept Christ in our life.  During my last bout of depression, a well-intentioned family member told me they did not understand why I was sad since I had such a great life.  Would anyone ever say that someone shouldn’t have diabetes because they have a great life?  Should I just “get over” having asthma because I have a good life?  If I have a heart attack, should I solely pray harder or should I pray, see my doctor, exercise, eat right, etc…?

One dictionary definition of stigma is a mark of disgrace associated with a particular circumstance, quality, or person.  I see bad metaphors of mental illness as stigmatized Scarlet Letters. This is the first of a series of blogs that will talk about some of the Scarlet Letters those of us that live with mental health issues are made to wear. This blog will also try to discuss ideas on how to turn that Scarlet Letter into a badge of merit instead of one of shame. We will begin by explore the stories of several people that have suffered from depression and its stigma.

Depression and Suicide: A Personal Blog

When I was asked to write about my experience as someone who suffers from depression in therapy, it seemed like an easy task.  However, once the writing started, there was so much to say that I realized it needed to be done in pieces. This is the first of three blogs on this topic. Robin Williams committed suicide during the writing of these blogs.  This blog is dedicated to him.

Many people do not understand how such a funny man as Robin Williams could not only suffer from depression but chose to end his life. Each person’s depression is different but there are many similarities in our illness. Please understand that depression is an illness just like cancer, high blood pressure and diabetes. Just like any of these other illnesses, depression does not discriminate against whom it attacks. Just like the other illnesses that were mentioned depression is hereditary. Just like the other three illnesses, you never know when it could first happen.

How could such a seemingly happy man not just suffer from depression but kill himself? Describing how depression changes your thought process is not an easy thing to do for someone who is not a scientist or a doctor but a sufferer themselves.  I am usually a happy person who loves talking to others, eating and to learn, but when I am depressed, I change.

Think about how you feel when you are hungry and your usual lunch hour has come and gone. You are hungry but you do not have time to stop to eat. The longer you go without eating the crankier you get. Suddenly the small things your co-workers do that usually do not bother you are now annoying you. Rude things you usually would not say suddenly are coming out of your mouth and you cannot control it. This is the closest I can describe to one of my depressive episodes. Suddenly, my usually happy persona disappears.

When I first become depressed, I cannot tell that I am not my usually happy person until it gets worse. My joy in learning goes away. Normally, I love to read interesting facts and ask questions to my co-workers, but when I am depressed even the most interesting book has no appeal to me.  Normally, food is a source of happiness, but when I am depressed it is not interesting for me and even can make me sick to my stomach. Something in my brain switches and my happy inner voice is now telling me that I am worthless and that no one can love or appreciate me. This “depression” inner voice is so rough on you that it tires you out to a point you cannot do anything and you question your will to live.

How can a depressed person try to get better? The first and easiest thing to do is exercise. The movie Legally Blonde has the best quote on depression and exercise; “exercise releases endorphins, endorphins make you happy, happy people don’t kill their husbands, they just don’t.” Happy people also do not commit suicide. Second if you are depressed look for help in the form of therapy. In the last blog on depression, how to find the right therapist was detailed. Finally talk to your doctor or a psychiatrist about if your depression is bad enough to be prescribed anti-depressants.

What if you are not the person suffering from depression but a loving family member or friend? What can I do for them? How can I help them? These are hard questions to answer. Different people can react differently to you trying to help them. These are some things that my friends and family did to help me during several of my depression episodes.

1)      Call, text, or email to send a small message letting them know that you love them and are worried. While your inner voice tells you are worthless, others telling you differently can help.

2)      Do something unexpectedly nice.  My older brother is known to come into my house to fill my refrigerator with food when he knows I am depressed. The idea being that he knows I will not do it and maybe I will not eat but if I do want to eat, the food is ready for me. My mom takes it to the next level and has not only made me food she’s fed it to me the same way she did when I had a cold as a little girl or when I’ve had surgeries.

3)      Ask about their safety.  Both my best friend and I once took away another friends medications and dispensed them to her on a daily basis so she would not try to overdose on them.

4)      Involve them in social activities. My brother and sister-in-law came to my house and made me come out to the movies with them once. I had not seen daylight in a week and that small interaction with humans helped.

While I was depressed, I did not always feel the above things were helpful.  None of the things I mentioned that my friends and family did for me were appreciated at the time. Remember that your reaction to them helping them is not them – it is their depression.

Looking back on it now, I am beyond grateful.  These small things that were done for me are the reason I am alive today.  If you suffer from depression, please hear that things can get better even if at the moment it does not seem like it.

Patient gives tips on how to see a psychotherapist

This guest blogger writes about what she’s learned about getting into therapy.  The following practical steps are helpful to people who could be helped by – but have never gone to-  therapy.

Therapy is a strange thing if you have never been before. You sit across a total stranger who asks you open ended questions about your most intimate most private thoughts and moments. You not only answer these questions honestly but you do it willingly. As you answer their questions, they give you, advice and opinions on the problem you went to see them for. You listen to their advice because their years of schooling and experience. The strangest part is if you answer honestly and do the work, they ask you, you can slowly see progress with the issue you came for help with. This can only happen if you know what to look for to find the right therapist for you.

How do you find a therapist? The easiest way to find one that takes your insurance is to call your insurance and to ask for providers that take your insurance. They can give you a list of providers closest to you. The number you can call to ask can be found in the back of your insurance card. You can also go to your insurance provider’s website and look for a mental health provider that way. Another way to find a provider is by word of mouth. Ask your friends and family for recommendations on health providers that they personally know. If you choose a health provider this way you will want to call either your insurance or the provider themselves to ask if they take your insurance.

There are some important things to know about the therapist you choose and your insurance before you start therapy. For your therapist you want to know where they went to school and their credentials. For your insurance, know what your copay is. Some insurances charge you the same copay as they would if you were seeing any other specialists. Other insurances charge you the same as if you were seeing your primary doctor. Finally, you should also know about the mental health parity law. The Bureau of Professional and Occupational Affairs is a good way to check on your therapist’s credentials. The things you need to know are if the therapist you have chosen is licensed and if any complaints have been filed against them with the states licensing board. The therapist having a license means that the state granting the license has assured that they have had up to 3,000 hours of required supervised experience. If any complaints were filed against the therapist, what were they and how were they settled. You can check with your state’s the licensing board to see if the therapist you have chosen is under investigation.

To know what your co-pay for seeing your therapist look at your insurance card. On the front of your insurance card, the prices for your co-pay are there. Calling your insurance will let you know if your copay is that of a specialist or the same as your primary doctor. Due to the Mental Health Parity Law, your insurance cannot charge you a higher co-pay than that to see a specialist. Your insurance also cannot limit the amount of visits you have per year to your therapist. Before 2008, insurances could and usually did limit how many visits you had per year. If your insurance refuses to pay for your mental health, they are required to tell you why they have refused to do so.

Knowing all these things can help you begin a great therapy experience. There are other things, which can help you have a good therapy experience. What some of these things are will be discussed in other blogs from the viewpoint of someone who is not only not only in therapy herself but also works in the mental health field. Hear her story of being in therapy, the stigma, and how she sees herself before therapy and while she has been in therapy.

Obamacare: The Future of HIV Treatment in Philadelphia?

The following is the background research and content for a presentation given at the AIDS Education Month Prevention and Outreach Summit at the Philadelphia Convention Center. It updates this blog after a long hiatus.

Goal: To give an overview of how Obamacare (ACA) is impacting Philadelphians living with HIV and what is likely ahead for those in HIV treatment in Pennsylvania.

The ACA is complicated legislation and there is a need for presentations like this one to help ensure people understand these new health care coverage options and to provide eligible individuals assistance to secure and retain coverage.

The Current System: The ACA is helping Philadelphians by 1) expanding coverage and 2)new patient protections. So far, the expanding coverage has been through The Health Insurance Marketplace.

For this last open enrollment, you were eligible to by Health Insurance if you made over:
$11,670 for individuals
$15,730 for a family of 2
$19,790 for a family of 3
$23,850 for a family of 4

Through the Health Insurance Marketplace Pennsylvanians can compare qualified health plans, get answers to questions, find out if they are eligible for lower costs for private insurance or health programs like Medicaid and the Children’s Health Insurance Program (CHIP), and enroll in health coverage.

At the end of the first annual open enrollment period, enrollment in the Marketplace surged to eight million people nationwide. In Pennsylvania alone, 318,077 individuals selected a Marketplace plan.

Of the Pennsylvanians who selected a plan:
54% are female and 46% are male;
33% are under age 35;
73% selected a Silver plan, while 8% selected a Bronze plan; and,
81% selected a plan with financial assistance.

Although open enrollment for 2014 coverage is over, the next open enrollment period begins on November 15, 2014 for coverage that can begin as early as January 1, 2015.

Pennsylvania has received $35 million in grants for research, planning, information technology development, and implementation of its Marketplace.

Unlike the Marketplace that has an open enrollment period and special enrollment throughout the year, enrollment in Medicaid and CHIP is open year round. An additional 40,988 Pennsylvanians enrolled in Medicaid and CHIP through the end of March 2014, compared to enrollment before the Marketplace opened October 1, 2013. To find out if you are eligible for Medicaid or CHIP visit or if you prefer Spanish.

Under the health care law, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old. Thanks to this provision, over 3 million young people who would otherwise have been uninsured have gained coverage nationwide, including 91,000 young adults in Pennsylvania.

As many as 5,489,162 non-elderly Pennsylvanians have some type of pre-existing health condition – including people living with HIV, as well as 656,877 children. Today, most insurers can no longer deny coverage to anyone because of a pre-existing condition, like asthma or diabetes, under the health care law. And they can no longer charge women more because of their gender.

Health insurance companies now have to spend at least 80 cents of your premium dollar on health care or improvements to care, rather than administrative costs like salaries or marketing, or they have to provide you a refund. This means that 123,581 Pennsylvanians with private insurance coverage benefited from nearly $7 million in refunds from insurance companies in 2012, for an average refund of $77 per family covered by a policy.

In every State and for the first time under Federal law, insurance companies are required to publicly justify their actions if they want to raise rates by 10 percent or more. Pennsylvania has received $5,312,084 under the new law to help fight unreasonable premium increases. Since implementing the law, the fraction of requests for insurance premium increases of 10 percent or more has dropped dramatically, from 75 percent to 14 percent nationally. To date, the rate review program has helped save Americans an estimated $1 billion.

The law bans insurance companies from imposing lifetime dollar limits on health benefits – freeing cancer patients and individuals suffering from other chronic diseases from having to worry about going without treatment because of their lifetime limits. Already, 4,582,000 people in Pennsylvania, are free from worrying about lifetime limits on coverage. The law also restricts the use of annual limits and bans them completely starting in 2014.

What does all this mean to Pennsylvanians living with HIV?

It depends on what your insurance status was before ACA implementation.
1) If you had private insurance, it might have given you an option to buy into the Health Insurance Market place if your plan cost too high a percentage of your income or your plan didn’t have minimum Essential Benefits. However, most people kept their private plans.
2) If you already had Medicaid, the ACA doesn’t impact you directly very much.
3) If you had Medicare, the ACA is progressively closing the “donut hole” in drug benefit coverage. In 2013, people with Medicare in the “donut hole” received a 52.5 percent discount on covered brand name drugs and a 21 percent discount on generic drugs. And this will continue to increase until there is no more “donut hole.”
4) The biggest change is if you were uninsured and working. The Health Insurance Marketplace is a historic opportunity to get heavily subsidized health insurance.
5) Now, many Pennsylvanians who have SPBP believe they had health insurance, but it only covers medications and labs. The HIV clinics cover their cost of services, but this leaves you without coverage for hospital stays, specialty care, home health, and many other important services.
6) One of the biggest changes is directly to HIV clinics themselves. While this might not seem like it directly impacts patients, if you like your HIV clinic and you want to keep going there- this does impact you. While the elaborate complexities of HIV Clinic funding is beyond the scope of this talk, I’d like to talk a little about how the ACA will likely impact HIV Clinics. Some have argued that the ACA renders the Ryan White Program redundant because “everyone” has health insurance, while others, including Neeraj Sood and colleagues, urge continuation of the program because of the proven benefit of its wraparound approach to care for people living with HIV/AIDS. Reauthorization of the Ryan White Program has been stalled in Congress since the latest funding measure expired in September 2013.
7) Finally, if you are uninsured , don’t work, and are currently ineligible for Medicaid, you could be eligible for Medicaid if Pennsylvania leadership allows the ACA to expand Medicaid. Part of the expansion is also simplification: eligibility criteria would be simplified down only to income level and not the current system of categories.

Pennsylvania Governor Tom Corbett has consistently refused to expand Medicaid in the Commonwealth and proposed a plan called Healthy Pennsylvania, which has some similarities to an Arkansas plan that was accepted. Because Healthy Pennsylvania, unlike the Arkansas plan, contained provisions that created more restrictions on current Medicaid recipients, the Obama Administration rejected Healthy Pennsylvania. The Governor offered to amend Health Pennsylvania so that it no longer includes the restrictions on current Medicaid recipients and there is wide speculation that the amended plan will be accepted in the Summer of 2014. In the absence of expanded Medicaid plans in Pennsylvania, Pennsylvanians under 100 percent of Federal Poverty Level (FPL) do not have increased access to health care at this time. Also, Pennsylvanians between 100 and 133 FPL are not eligible for Medicaid at this time.
Under the ACA, individuals with incomes between 100 to 400 percent Federal Poverty Level (FPL) may be eligible to receive advance payments of premium tax credits and/or cost-sharing reductions to help pay for the cost of enrolling in qualified health insurance plans and for coverage of essential health benefits.

Increased access to insurance : Open Enrollment and Special Enrollment Periods
We’ve worked with patients who have said they can’t buy through the Health Insurance Marketplace because Open Enrollment has closed. Fortunately, there are many reasons you can buy through the Marketplace throughout the year. We will quickly run through the reasons you can quality for a Special Enrollment Period.

Did you or anyone in your household lose health coverage in the last 60 days OR do you expect to lose it in the next 60 days?
Examples of coverage loss that qualify you for a special enrollment period (voluntarily giving up coverage does not qualify you for a special enrollment period):
Lost coverage due to divorce
Policy or plan year ended for policy you bought yourself
COBRA coverage expired
Turned 26 and aged off a parents health plan
Lost eligibility for Medicaid or CHIP

Did you or anyone in your household experience any of the following in the past 60 days?
Got married
Had a baby
Got divorced
Adopted a child or had a child placed for foster care
Death of person whose insurance you were on
Moved to a new address
Had a change in income
Gained citizenship or lawful presence in the U.S.
Released from incarceration (prison or detention)
Are you a member of a federally recognized tribe, or an Alaska Native?

Existing coverage gap: The (controversial) Individual Mandate.
The ACA requires people to carry health insurance only if it is affordable. If worker premiums for adequate employer-sponsored coverage cost less than 9.5% of household income, insurance is deemed “affordable.” Employed workers with an offer of such affordable coverage do not qualify for tax credits through the health insurance exchanges. The administration found, to its dismay, that the law bases affordability on the premium for single-worker coverage, even for workers with dependents whose premiums are higher.

The ACA provides a new tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return. (This is called premium tax credit.)

Philadelphia needs to help the formerly incarcerated.
Compared with the general public, people who populate jails—disproportionately male, minority, and poor—have higher rates of communicable diseases such as HIV/AIDS; tuberculosis; mental illnesses and substance abuse disorders; and chronic conditions, including asthma, diabetes, and hepatitis B and C. Regardless of where these people reside, it is important that their conditions be treated, particularly because currently 95 percent of them return to the community without coverage.

If Medicaid expansion occurs in PA, the ACA will offer coverage to people released from jails by reducing the financial barriers through Medicaid expansion (in twenty-six states thus far) and subsidized insurance through exchanges.

The ACA does not change Medicaid’s prohibition on paying for eligible services while people are incarcerated; once jailed individuals are released, benefits could accrue to those who are eligible and enroll. Some researchers estimate that 25–30 percent of people released from jails could enroll in Medicaid in expansion states and that about 20 percent could enroll in an exchange, depending upon their reported income. But this will occur only if correctional facilities and community providers work more closely together. Fortunately, there are several initites to do just this for Pennsylvanians living with HIV/AIDS.

Protections for Pre-existing conditions like HIV
The ACA prevents health insurance companies from raising rates or denying coverage because of a pre-existing condition like HIV/AIDS, cancer, or mental health concerns – or because they happen to be LGBT.
Thanks to the ACA, insurance companies can no longer impose a lifetime limit on coverage. This is particularly important to HIV/AIDS patients, and anyone else who have a chronic condition.

The landmark civil rights provision, Section 1557 of the ACA, prohibits discrimination against individuals based on sex, which includes discrimination based on sex stereotyping and gender identity. While implementing regulations are being drafted, HHS is accepting complaints and enforcing the law.
Insurance companies are prohibited from discriminating against individuals on the basis of sexual orientation or gender identity, including against same-sex spouses with respect to an offer of spousal coverage. So it is now illegal for insurance companies that offer coverage to discriminate on the basis of sexual orientation or gender identity and legally married couples are treated equally when it comes to coverage and financial assistance.

Prior to implementation of the ACA, dollar caps on annual and lifetime coverage led to huge bills and crippling debt – or the inability to get care when it was most needed — for many individuals with chronic conditions such as HIV/AIDS. Now, lifetime and annual dollar caps are a thing of the past and no one can be denied coverage based on their health history.

Mental health and substance abuse parity
The ACA increases access to comprehensive coverage by requiring most health plans to cover ten essential health benefit categories, to include hospitalization, prescription drugs, maternity and newborn care, and mental health and substance use disorder services. The health care law expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans nationwide, including 2,260,075 Pennsylvanians.

For this to change, however, we need your advocacy. Specific people who have been denied behavioral health services need to be willing sue insurers in PA for this law to be effective in Philly. Please email this author at if you have been denied services.

The Health Insurance Marketplace Is Simple

by Kevin Moore, PsyD

Have you heard about the Health Insurance Marketplace recently? Did you see on television how it caused the government to shut down? Did you read in the newspaper a long list of abstract information? Did you hear on the radio the speculation that this or that will be changing? Are you unsure if the Marketplace applies to you or not?

I’m pleased to write this blog and tell you: the Health Insurance Marketplace is simple. I’m going to tell you how to find real information. If you are living with HIV/AIDS or work with people who do, I highly recommend you spend a few hours of your time and get direct answers rather than spending your time on second or third-hand media coverage. Beyond being complex, a lot of media coverage is inaccurate, sometimes wildly (e.g. I saw on Fox News that Obamacare is a Congressional Bill) or subtly (e.g. I read the ACA Wikipedia page and counted 3 small factual mistakes in the Overview of Provisions.)

So here is the deal, and it can be said in just one sentence: If you don’t have medical insurance (or you feel you pay too much for insurance) and you file taxes for $11,490 or more as a single person (or add $420 per person in your family), go to and thoroughly read your options. That’s it. It is honestly that simple. Plus, its the only way to know for sure.

Just like picking a cell phone plan, you will be walked through coverage options and payment information. You will learn about co-pays, co-insurance, deductibles, and spending limits. It will explain the benefits that are covered. You can stop reading and come back later to read more. If you are someone who has relied on Ryan White clinics for your medical care, this might be your first opportunity to receive coverage for emergency care, hospital stays, and rehabilitation services that Ryan White does not cover. You can not be discriminated against and denied healthcare because you have HIV. The only health condition that can increase your costs is if you smoke. But don’t take it from me, go to and see.

You may have heard the website is down. It has been difficult to access in its first week, but it has never been down. You might want to wait a week or two after the posting of this blog to check out the website, but don’t take too much time. I’d recommend you check it out before December 7th to insure you have coverage starting January 1.

If you work with uninsured people with HIV/AIDS, I recommend you offer to sit down with them at the computer and walk through the options with them. There are Patient Navigators and Certified Application Counselors who can assist them, but,  really, even they can be confused and only has the complete and accurate information. When you are sitting and helping, there is an option on the website for the patient to name you as a “non-navigator patient assister.” This means you aren’t claiming to have any knowledge but are acting in a professional capacity to try to help. Yes, it will take several hours to move through all the information, but you can reassure them that they can do it.

The Health Insurance Marketplace is simple.

AIDS Service Organizations transitioning into the Affordable Care Act, Part Two: Medicaid Expansion and Health Insurance Marketplace

Posted on: 1 Comment

By Kevin Moore and Erica Goldberg

The majority of people with HIV are poor and uninsured. This can be attributed to the fact that most people living with HIV are unemployed, which is in turn due to a myriad of factors including social, psychological, and medical factors surrounding the disease. Because the pre-ACA United States primarily tied insurance to employment (rather than insurance to citizenship), the largest group of people with HIV have always had to turn to disability benefits such as Medicaid and Medicare and/or the Ryan White system of care. According to a recent Kaiser Healthcare Report, Americans living with HIV accessed care through the following coverage:

42% Medicaid (including dual Medicaid/Medicare)
13% private insurance
24% no coverage
(The reason this percentage does not equal 100% is because not all people with HIV are accessing care, a topic of a future blog.)

One main tenant of the ACA was to get as many people insured as possible. In order to achieve this, Medicaid expansion was made a top priority. In states that are expanding Medicaid, the federal-state insurance program for low-income Americans, will be available without restriction to people up to 138% of the federal poverty level, which for single adults is $15,856 in 2013. We note “without restriction” because in states that do not expand Medicaid, not everyone who makes less than 100% of federal poverty level (i.e. $11,489) is eligible because they are not disabled, pregnant, or one of the other allowable categories.

For those who do not know, we think it is important to understand that in America today you can make less than $31 a day and not be able to see a doctor.

Pre-ACA requirements dictate that after you have attained Medicaid, you have to keep re-enrolling in Medicaid or lose your coverage. Here in Pennsylvania, the Department of Public Welfare adopted new rules in 2012 which allowed lots of people to be kicked off of Medicaid because of heightened re-enrollment requirements. One of the many benefits of expanding Medicaid is re-enrollment wouldn’t be an issue unless you started making significantly more money.

The second way the ACA gets more people insured is the creation of the Health Insurance Marketplace, which allows individuals from 138%-400% of the federal poverty level to purchase insurance with assistance of a significant tax credit. The Health Insurance Marketplace is an internet website,, which provides a single application for both the Marketplace and or Medicaid. There is also a paper version. The Marketplace will open on October 1st and the plans will become active January 1, 2014.
There is a new “live chat” feature on , a small black rectangle with the words “Questions? Live Chat” pops up in the bottom right-hand corner of pages as you navigate through the site. Click on it to chat online with trained professionals and ask questions. If you prefer to talk in-person, a new hotline was also recently launched. It offers 24/7 access via telephone to trained representatives who can also help answer your questions about the Marketplaces. The toll-free number is 1-800-318-2596 and the TTY line is 1-855-889-4325.

A marketing campaign is currently underway to raise public awareness about these options. Please be part of it. These changes are very complex and require multiple exposures and explanations to effectively communicate the information to those it will assist. These are our patients, our friends, and ourselves as providers, who are affected by these changes. You can help by talking about these changes with your friends and family.

If you don’t know what your state is doing about expanding Medicaid, you can find out here:

If you are in a state that is not expanding, please use the following tool that was prepared by the Duke AIDS Legal Project to understand your options for the Health Insurance Marketplace.

Can you prove US citizenship or legal residence? ☐ NO. Stop here. You CAN’T buy insurance in the marketplace

☐ YES. Go to the next question

Do you have Medicaid or Medicare? ☐ YES. Stop here. You CAN’T buy insurance in the marketplace

☐ NO. Go to the next question

Does your employer offer insurance that
a) Is affordable (costs less than 9.5% of household income to cover you)
b) Has decent benefits (eg “mini-med” doesn’t count) ☐ YES. Stop here. You CAN’T buy insurance in the marketplace

☐ NO or you’re unsure. Go to the next question

Does your spouse’s employer offer insurance that
a) Is affordable (costs less than 9.5% of household income to cover your spouse)
b) Has decent benefits (eg “mini-med” doesn’t count)

☐ YES. Stop here. You CAN’T buy insurance in the marketplace

☐ NO or you’re unsure. Go to the next question.

Is your income lower than column A in the Income Table on the table below? (Use your best guess for your income.) ☐ YES. Stop here.
• You CAN buy insurance, but can’t get help with the cost
• You are exempt from the requirement to have insurance

☐ NO. You CAN buy insurance in the marketplace. Go to the next question to find out about help with costs.

Is your income higher than column C in the Income Table below? ☐ YES. Stop here. You MUST to buy insurance or pay a tax penalty. You can’t get help with the cost.

☐ NO. You CAN buy insurance in the marketplace AND get help with the cost. Go to the next question.

Is your income higher than column B in the Income Table on the next page? ☐ NO. You SHOULD apply for insurance and financial help, but won’t owe a tax penalty if you don’t buy.

☐ YES. You MUST apply for insurance, and will owe a tax penalty if you don’t buy (unless you qualify for an exemption).

• Use the above form to identify ADAP clients who may be
 able to buy health insurance through the Insurance Marketplace
 able to get financial help with costs, and/or
 required to obtain coverage

• Clients who may be eligible should be encouraged to enroll in insurance and find out how much financial help they can get. Clients will be able to shop online and compare cost, coverage, and providers. Financial help will include reduced or free premiums and reduced cost sharing.

• Open enrollment runs October 1, 2013 to March 31, 2014. Coverage starts January 1, 2014.

NOTE: This form attempts to simplify complicated rules so you can identify clients who should be prioritized for enrollment assistance after October 1. For questions about specific circumstances, clients should turn to consumer assistance resources that will be coming available over the summer of 2013, including:
• health insurance navigators (beginning mid to late August)
• Marketplace 24/7 call center – 1-800-318-2596
• Online enrollment portal for the marketplace (available at, going live October 1)

Marketplace Insurance Benefit Table

Numbers in the far left hand column are number in household Eligible for Financial Help with Costs Required to
Have Coverage Upper Limit for Help with Costs.

Lettered Income thresholds are the columns:
A. Eligible for financial help with costs: income over 100% of federal poverty level. People under this income level can buy insurance in the marketplace, but won’t qualify for financial help
B. Required to have coverage: income over 133% of federal poverty level (some exemptions apply). Coverage can come from employer, marketplace, government, or private market
C. Upper limit for help with costs: 400% of federal poverty level. People with incomes above this level can buy insurance, but won’t financial help (tax credit)

A                 B                C
1     12,065     15,856     46,535
2     16,286     21,404     62,816
3     20,507    26,951     79,097
4     24,728     32,499     95,378
5     28,949     38,047     111,659
6     33,170     43,594      127,940
7     37,391     49,142      144,221
8     41,612      54,689      160,502

Incomes listed above are increased to account for a 5% income disregard.