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, www.healthcare.gov, 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 www.healthcare.gov , 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: http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
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.
INSURANCE MARKETPLACE PRE-SCREENING
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).
INSURANCE MARKETPLACE PRE-SCREENING
• 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 healthcare.gov, 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.