Paying for HIV Care and Treatment
Paying for HIV Care
HIV care and treatment involves taking HIV medicine called antiretroviral therapy (ART) and having regular check-ups with your health care provider who will monitor your health status on an ongoing basis.
These things are important because with the proper care and treatment, you can reduce your viral load, protect your health, enjoy a long and healthy life, and prevent transmitting the virus to others.
But you might have concerns about how to pay for this. There are resources that can help you pay for the care you need.
Job-Based and Individual Insurance—Many people have private health insurance through their employer (or a family member’s employer), or they have individual insurance they have purchased. Under the Affordable Care Act (ACA), most job-based and individual plans are required to offer new benefits and protections. For example, plans can’t drop you or deny you coverage just because you have a pre-existing health condition, like HIV. And insurers can’t impose lifetime caps on your insurance benefits. However, you’ll still need to pay any deductibles, copayments, and coinsurance your plan requires. Make sure you read your plan carefully so that you know what your plan will (and won’t) cover.
When you leave a job, you may be able to keep your job-based health insurance for a period, usually up to 18 months. This is called COBRA continuation coverage. With COBRA coverage, you usually have to pay the entire monthly premium yourself, plus a small administrative fee. Your former employer no longer pays any of your insurance costs.
The Health Insurance Marketplace—Established under the ACA, the Health Insurance Marketplace, available at Healthcare.gov, helps uninsured people find and apply for quality, affordable health coverage. Private plans in the Marketplace are required to cover a set of essential health benefits, including HIV screening, STI prevention counseling, and PrEP. And, low and middle-income people may qualify for lower costs, based on their household size and income. To see if you can enroll in a health insurance plan or change plans, visit HealthCare.gov or find local help. Some states run their own health insurance exchanges. You can still get connected to them through HealthCare.gov.
Open Enrollment for 2023 Coverage
The Marketplace Open Enrollment Period for 2023 runs November 1, 2022 – January 1, 2023. Enroll by Thursday, December 15, 2022, for coverage that starts January 1, 2023. Get steps for how to apply and enroll.
Still need coverage for 2022? You can still get or change plans if you have certain life events, like losing coverage, moving, or getting married, or if you qualify for Medicaid or CHIP. Learn more about health coverage outside Open Enrollment.
If you do not have private health insurance—or need help because your insurance doesn’t pay for the HIV care and treatment you need—there are federal resources that may help you.
Getting Help—Figuring out which programs and services you qualify for can be confusing. But don’t worry! There are case managers and benefits counselors who can help you. They know what services are available and can help you get care. Their services are free. Someone may provide this service at your health care provider’s office or clinic. You also can find one near you by contacting a local HIV/AIDS service organization. Toll-free State HIV/AIDS Hotlines will help put you in touch with agencies that can determine what programs and services you may be eligible for and help you access them.
Here are federal resources that are available:
- Medicaid—A state and federal partnership, Medicaid provides coverage for people with lower incomes, older people, people with disabilities, and some families and children. It is a critical source of coverage for many people living with HIV. States establish and administer their own Medicaid programs and determine they type, amount, duration, and scope of services within broad federal guidelines. States are required to cover certain mandatory benefits and can choose to provide other optional benefits, including prescription drugs. The eligibility rules for Medicaid are different in each state, but most states offer coverage for adults with children at some income level. And, under the ACA, states have the option, with significant federal matching funds, to expand Medicaid eligibility to generally include people below certain income levels, including low-income childless adults who were previously not generally eligible for Medicaid. As a result, in states that opt for Medicaid expansion, people with HIV who meet the income threshold no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. You can apply for and enroll in Medicaid at any time. There is no limited enrollment period. If you qualify, your coverage can begin immediately. As of September 2022, 39 statesExit Disclaimer (including DC) have adopted the Medicaid expansion and 12 states have not adopted the expansion. Even if your state hasn’t expanded Medicaid, you should still apply for coverage to see if you qualify under your state’s existing rules. See if you qualify to save in your state.
- The Ryan White HIV/AIDS Program—The Ryan White HIV/AIDS Program works with cities, states, and local community-based organizations to provide HIV-related services to more than half a million people living with HIV each year. The program is for those who do not have sufficient health care coverage or financial resources to cope with HIV disease. Ryan White fills gaps in care not covered by these other sources. The program is divided into several “parts” to meet the needs of different communities and populations, and includes support for an AIDS Drug Assistance Program (ADAP). To find a Ryan White clinic near you, use the HIV Testing and Care Services Locator.
- The Health Center Program— Health centers provide high quality preventive and primary health care services, including HIV testing and medical care, to patients regardless of their ability to pay. Some patients receive services directly at the health center itself, while others are referred to an HIV specialist in the community. Major investments in the network of community health centers over the past several years have created more opportunities for HIV care delivery. You can find a health center near you by going to the HIV Testing and Care Services Locator.
- Medicare—Medicare is health insurance for people aged 65 or older, people under 65 with certain disabilities, and people of all ages with End-Stage Renal Disease. Medicare coverage for eligible individuals includes outpatient care, prescription drugs, and inpatient hospital care. It covers all medically necessary treatment for a person with HIV. To learn more about Medicare coverage and choices, visit Medicare.gov.
Need Medicare Coverage?
When you first become eligible for Medicare, you can join a plan.
Then, during the annual Medicare Open Enrollment Period (October 15 – December 7), you can join, switch, or drop a plan. Your coverage will begin on January 1. The Medicare Advantage Open Enrollment Period is January 1 – March 31 each year.
- Federal Programs for Women and Children—There are several federal programs to help low-income women and children access health care. The Children’s Health Insurance Program (CHIP) provides free or low-cost health insurance coverage for children up to age 19. Each state has its own rules about who qualifies for CHIP. You can apply for and enroll a child in CHIP at any time. There is no limited enrollment period. If the child qualifies, his/her coverage can begin immediately. Visit www.insurekidsnow.gov to learn more and see if you are eligible for coverage or call 1-877-KIDS-NOW (1-877-543-7669). In addition, programs supported by the Maternal and Child Health Services Block Grant, authorized by Title V of the Social Security Act (SSA), serve low-income women, children, and youth with limited access to health care, including children with special needs. Specifically, the Title V Maternal and Child Health program seeks to assure access to quality care, especially for those with low-incomes or limited availability of care.
- American Indian and Alaska Native Programs—The Indian Health Service (IHS) provides health care services—including HIV services—for members and descendants of federally-recognized American Indian and Alaska Native Tribes. For more information, visit IHS.gov.
- Veterans Programs—The Department of Veterans Affairs (VA) is the largest single provider of medical care to people with HIV in the U.S., supporting over 31,000 Veterans with HIV. If you are eligible, you may be able to receive HIV care through the Veterans Health Administration. VA offers an online benefits website with detailed information about health care benefits.
Patient Assistance Programs (PAPs) are programs administered by pharmaceutical companies to offer free or reduced-cost antiretroviral (ARV) medicines to low-income people living with HIV who are uninsured or underinsured, and who do not qualify for federal assistance programs such as Medicaid, Medicare, or AIDS Drug Assistance Programs. Each pharmaceutical company has different eligibility criteria for qualifying for their PAP.
The U.S. Department of Health and Human Services, seven pharmaceutical companies, NASTAD (formerly the National Alliance of State and Territorial AIDS Directors), and community stakeholders worked together to develop a common patient assistance program applicationExit Disclaimer (CPAPA) and companion documentExit Disclaimer that can be used by patients and providers to access these programs.