HIV patients wade warily into health marketplace

Up to now, most HIV-related medical care for him and other low-income, uninsured patients in Virginia has been paid for by government grants.

Starting this year, they will be enrolled in health insurance through the Affordable Care Act's marketplace.

The new plans cover not just HIV care, but also other medical needs. That means Jeremy might finally be able to see a specialist to find out why one medication makes him nauseous and another makes him so dizzy that he can't drive.

But he's not rushing to make any appointments yet. In fact, he's canceled four because he's concerned about the copays and cost sharing required by his new policy.

"I'm not going to run up bills and expect somebody else to pay until I know for a fact that they're going to pay," said Jeremy, 34. He asked that his last name not be published.

A patchwork of government grants through the federal Ryan White Program has been covering prescription drugs and some medical care for HIV- and AIDS-related ailments in lower-income patients.

Now, one of those initiatives - Virginia's AIDS Drug Assistance Program - plans to pay monthly premiums and medication costs for patients eligible for marketplace policies.

In Virginia, the move could save millions at a time when funding is desperately needed.

Enrollment in the state AIDS Drug Assistance Program is at an all-time high at 5,200. It continues to grow faster than ever, thanks to guidelines recommending an earlier start to treatment, more funding for HIV testing, and efforts to keep people from dropping out of care.

Marketplace plans will allow the program to be more cost-effective, said Steven Bailey, director of HIV care services for the Virginia Department of Health. With insurance paying some of the bill, the program can reduce its spending to an average of $8,000 per patient per year, compared with $11,000, the previous average for medication alone.

Patients stand to gain from the switch because private plans provide coverage they don't have - for hospital and emergency care, as well as medical needs unrelated to HIV or AIDS.

The policies require members to pay a share of the bills for doctor visits and laboratory tests until they reach an out-of-pocket maximum - expenses that, when they involved HIV-related care, were covered by Ryan White funds in the past.

Medication costs paid by the drug-assistance program will allow patients to hit the maximum within about four months, Bailey said.

But until then, it will be up to others receiving Ryan White money - including cities and health care providers - to determine how copays and coinsurance not related to medications are covered.

In states that choose to expand Medicaid eligibility, as the Affordable Care Act allows, the poorest patients are covered by that state-federal program. So far, Virginia has opted out.

In the past few weeks, Jeremy has spent hours making calls and writing letters, trying to figure out whether his costs would be covered.

"At one point, I was yelling," said Ripley, 48, who lives in Hardyville, northeast of Gloucester. He supports his partner and ill mother with a monthly $1,700 disability check.

Christine Carroll, program manager for the Ryan White Part A grant, which covers southeastern Virginia and northern North Carolina, said either that grant would pay out-of-pocket costs that aren't covered for local patients, or administrators would arrange for the costs to be covered through another grant.

The budget beginning March 1 includes money earmarked for such expenses, and other funds can be shifted, she said.

"It's going to take some time. It's going to take a lot of education," Carroll said. "And I'm sure there's going to be some trial and error, but I think that eventually it will all smooth out, so hopefully nobody will get lost in the midst of it all."

That money and other Ryan White grants will help pay costs for low-income HIV and AIDS patients at clinics run by Eastern Virginia Medical School.

Dr. Edward C. Oldfield, director of the EVMS Center for the Comprehensive Care of Immune Deficiency, also has worried about how low-income patients would pay their shares of health costs under the insurance plans.

He said that he was glad their needs would be taken care of, but that a lot of work was necessary to figure out the logistics.

"Now we have the potential to make it work," he said. "A week or two ago, we had no idea what was going to happen."

Bailey, the state's director of HIV care services, said that he hoped to enroll about 3,000 patients from the drug-assistance program in marketplace plans, but that finding workable insurance policies hasn't been simple.

Some plans don't cover certain HIV drugs. Some require multiple prescriptions for the component drugs in a single tablet. That makes it harder for a patient to stay on a regimen that requires strict compliance.

Also, because of Ryan White funding rules, patients in the drug-assistance program can sign up only for plans that cover all HIV medications included on the program's formulary.

Plans from Anthem Blue Cross and Blue Shield of Virginia don't include them all. That means none of the program's clients can sign up for an Anthem policy.

Although the health care law prohibits insurance companies from denying coverage or charging more because of a pre-existing condition, the approach taken by the state's biggest insurer means it will avoid enrolling some of Virginia's most expensive patients.

Scott Golden, an Anthem spokesman, said in an email that the insurer's plans meet requirements for the marketplace and cover many of the drugs used for HIV and AIDS treatment, including one of the most popular.

"Our goal in developing our marketplace products was to balance the need for affordability with choice," Golden wrote. "To help lower premiums for our members, we developed an affordable drug list with quality choices."

In southeastern Virginia, patients in the drug-assistance program have just one option for an insurance company: Optima Health, the insurance arm of Sentara Healthcare.

He doubts that insurance will help him much until a $6,250 out-of-pocket maximum is met. That could take months.

He's also wary of promises that his copays and coinsurance will be covered: "Until I see it in writing and I actually have it in black-and-white, I don't believe anything."

Ripley was told that his doctor visits will be covered the way they used to be until April 1. He continues to worry about what will happen next, but he's hopeful about having insurance.

"I still feel the pro outweighs the con," he said. "At the end of the day, when all of it's all worked out, I have access to care that I didn't have at the end of December."

“... Jeremy might finally be able to see a specialist to find out why one medication makes him nauseous and another makes him so dizzy that he can’t drive.”

Yeah, it’s hard to trek by foot all the way to those highway rest stops.

<I get that people with this self-inflicted disease

The disease is not entirely self-inflicted. When I practiced law, I did pro bono work for an AIDS group. I had one gay man client, but all the rest were several straight white women who had been infected by their husbands.

I’m in another field now, but I understand that black women are frequently infected by their husbands/boyfriends who come back from prison.

While I think we’ve solved the problem of getting AIDS through a blood transfusion, some people who may still be alive now did get it that way. It wasn’t self-inflicted.

I get that. The only one you mention that did not start out as self-inflicted is from transfusion.

A husband that transmits it has to contract it first.

Yes there are innocents that end up with it, like an unsuspecting wife - but the husband went out and got it being a pig. Being perverted. Sorry if I offend, but I consider such men to be sick disgusting perverts, and I feel pity for the women.

we constantly admit the same sloth meth users who are also diabetics....they're in for acidosis, or abcesses, or cellulitis, or osteomylitis, or urinary tract infections....

free room and board, call and get whatever you want to eat, clean sheets, free narcotics and benzo's for "anxiety" and then they get discharged, start shooting up again, sharing needles, drinking, ignoring their diabetes or other health problems...

its a swinging door and no one can stop them from doing this except Father Death....

marginzac wrote:
“But...but..you’re not allowed to ASK because it’s being “judgemental”, dontchaknow...
just shut up and pay up.....”

Wasn’t it also “judgemental”, when the entire homosexual community, in the entire Los Angeles Basin, in 1984, stated that they were going to taint the entire Red Cross blood supply of the area, by donating blood, and denying that they were HIV-positive/AIDS-positive, or not?

He asked that his last name not be published.

Why not? This will all be public knowledge when all our records are online. Just one data breach away....

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