Paying for HIV Care and Treatment
How Do You Pay 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. You can pay for HIV care with private insurance or there are federal programs that can help you pay for care if you are uninsured or underinsured. There are also nonfederal patient assistance programs and co-payment assistance programs that may help you with free or low-cost HIV medications.
Paying for HIV Care with Private Insurance
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 certain 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.
Finding Individual Coverage on 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.
Need Marketplace Health Coverage?
The Marketplace Open Enrollment Period for 2024 is closed. However, you can still get or change plans through a Special Enrollment Period if you have certain life events, like losing coverage, moving, getting married, or having a baby. Learn more about special enrollment opportunities.
Also, see if you qualify for Medicaid or CHIP. Medicaid and CHIP can provide free or low-cost health coverage to low-income people, families and children, pregnant women, the elderly, and people with disabilities. If you are eligible, you can enroll at any time; there is no open enrollment period. Find out if you qualify and get steps to apply.
Federal Programs to Help People Who Are Uninsured or Underinsured Get HIV Care
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.
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. Below 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 with HIV. States establish and administer their own Medicaid programs and determine the 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 2023, 41 statesExit Disclaimer (including DC) have adopted the Medicaid expansion; North Carolina’s Medicaid expansion will launch on December 1, 2023. 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 (RWHAP) works with cities, states, and local community-based organizations to provide HIV-related services to more than half a million people with HIV each year. The program helps low-income people with HIV get care, treatment, and support services. 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) for people who have limited or no health insurance. To find a Ryan White clinic near you, use HIV.gov’s HIV Testing and Care Services Locator.
The Health Center Program—Health centers provide high quality preventive and primary health care services, including HIV testing, PrEP, and medical care, to patients regardless of their ability to pay. Some people with HIV receive health care 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 HIV.gov’s 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, Title V programs supported by the Maternal and Child Health Services Block Grant, 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. Find state hotlines.
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. Find out how to apply for VA health care benefits as a Veteran or a service member.
Non-Federal Resources to Help Pay for HIV Medication
In addition to the federal programs listed above, there are non-federal resources that may help you with free or low-cost antiretroviral (ARV) medicines:
Patient Assistance Programs (PAPs)—PAPs are programs administered by pharmaceutical companies to offer free or reduced-cost ARV medicines to low-income people 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. View a list of these programs (PDF, 148 KB) and learn more about how to access them (PDF, 171 KB).
Co-payment Assistance Programs (CAPs)—CAPs are programs administered by pharmaceutical companies to help people who have insurance lower or eliminate the amount they owe as a deductible, co-insurance, and/or co-payment for a specific medication. Each pharmaceutical company has different eligibility criteria for qualifying for their CAP. View a list of these programs (PDF, 148 KB) and learn more about how to access them (PDF, 171 KB).