1. More help with co-pays and premiums if you get your HIV medications through your insurance. ACTION NEEDED: If you have private insurance and earn less than $54,450 a year, consider applying for ADAP.
• ADAP used to enroll only people whose private insurance required them to pay more than 20% of the cost of each prescription, or who had co-pays of more than $100. ADAP will now enroll anyone with private insurance and pay your out-of-pocket costs, including any deductibles and co-pays. Note that your private plan must be able to coordinate with the ADAP pharmacy. In addition, the insurance company cannot require prescriptions for more than a one-month supply of medication. (ADAP will not a fill a three-month supply.) In addition, you must meet the other ADAP eligibility requirements.
2. More help with co-pays and deductibles for people who get their HIV medications through a Part D Medicare Plan. ACTION NEEDED: If you have Medicare and your income is less than $54,450, consider applying for ADAP. You can get help paying for your medications.
• If you are on Medicare and your income is under $26,917, you are probably already getting help with your premiums and co-pays from either Social Security Extra Help or Illinois Cares Rx. Your Part D prescription drug premiums are being paid and you probably don’t spend more than about $6 for each HIV medication. ADAP can now help you with these small co-pays too. Every dollar is probably important to you, so enroll in ADAP and get help with those co-pays.
• If you are on Medicare and your income is over $26,917, but under the ADAP limit of $54,450, you probably couldn’t afford your HIV medications last year, and got them from ADAP. Effective January 1st, 2011, the Affordable Care Act (the 2010 health care reform bill) allows the money ADAP spends on your behalf on your HIV medications to count toward your out-of-pocket costs. What does this mean to you? This year, you can get your HIV medications from your Medicare Part D plan all year, and ADAP will pay your out-of-pocket costs for HIV medications. The money ADAP spends on your HIV medications will help you get out of the Part D “donut hole”. ADAP will continue to help with your co-pays for HIV medications once you are in the “catastrophic” phase of the Part D program. You only have to pay 5% toward your non-HIV medications.
• One caution: Some people on ADAP now never reach the donut hole for their non-HIV medications. That means they are paying 20% of the costs of their non-HIV medications all year long. With this change, they will reach the donut hole, and may have to pay 100% of the cost of their non-HIV drugs during the donut hole period.
• As with private insurance plans, your Medicare Part D plan must coordinate with the ADAP pharmacy in order for you to be able to take advantage of these changes.
3. New Health Insurance Option for People on ADAP.
• Have you been without insurance for six months or more? (ADAP or free medical care from a Ryan White clinic doesn’t count). If so, you may be eligible for the new Illinois Pre-Existing Insurance Plan (IPXP).
Another change that health care reform has already brought to Illinois is the establishment of a new insurance plan for people who are uninsured and unable to buy insurance on the private market. Premiums for this new policy range from $135 to $653 per month, depending on your age, where you live, and whether you are a smoker. Illinois CHIC will pay up to $500 toward your premiums and Illinois ADAP will also help with your co-pays and deductibles for your HIV medication. This is a tremendous opportunity for people on CHIC and ADAP to obtain comprehensive health insurance. More information is available here.
If you have questions, call Illinois ADAP at 800-825-3518 or visit the ADAP website. Note that as of February 7, the criteria listed on the ADAP application and website does not reflect the policies above, announced at a January 21, 2011 meeting of the ADAP Medical Issues Advisory Board.
Yes, it’s complicated! You can also get more information about any of these changes from the AIDS Legal Council of Chicago. Call toll-free from anywhere in Illinois, 866-506-3038.