Covered California Frequently Asked Questions For People Living with HIV and Hepatitis C and People Considering PrEP

While open enrollment will be shorter in some states, Covered California will have a full open enrollment period from November 1, 2017 – January 31, 2018. If you need your coverage to start on January 1, 2018, you must sign up by December 15, 2017 and pay your first premium by the due date.

There are two forms of federal financial assistance that help consumers purchase affordable coverage through Covered California:

• Advance Premium Tax Credit (APTC) – A federal tax credit you can take in advance to lower your monthly health insurance premium. You may qualify if your annual income is between 138–400% of the federal poverty level ($16,643–$48,240 for an individual).
• Cost-Sharing Reductions (CSRs) – A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. Cost-sharing reductions also lower your out-of-pocket maximum — the total amount you have to pay for covered medical services each year. You may qualify if your annual income is between 138–250% of the federal poverty level ($16,643–$30,150 for an individual). If you qualify, you must enroll in a Silver plan to get the extra savings.

On October 12, 2017, President Trump announced he would no longer provide federal funding for cost-sharing reductions. Information about the impact of this decision is included below.

Consumers who are eligible for cost-sharing reductions will continue to receive them. Plans are required to keep the deductibles, copayments, and coinsurance at the cheaper level regardless of whether they are reimbursed by the federal government. The advance premium tax credit is not changed by the elimination of funding for cost-sharing reductions.

Covered California planned ahead to protect most consumers from higher rates resulting from the elimination of cost-sharing reduction funding. Instead of using federal funding to pay for cost-sharing reductions, Covered California plans will add additional premium costs ONLY to Silver plans sold on the exchange for 2018 to make up for the loss of the cost-sharing payments. Covered California structured the additional premium charge in a way that protects most Californians from having to pay higher premiums:

• Most consumers who receive the advance premium tax credit will not see a change in the amount of premium they pay in 2018 because they will receive a higher amount of tax credit to offset the Silver plan premium increases. Consumers can also use these increased tax credits to purchase plans in other metal tiers. For consumers with incomes between 138-200% of the federal poverty level enrolled in more generous cost-sharing reduction plans, such as Silver 94 or Silver 87 plans, staying in that plan is likely the best option. Consumers with incomes over 200% of the federal poverty level in Silver 73 or regular Silver plans might also want to look at Gold plans, as in many regions there is at least one Gold plan that is cheaper than a Silver plan and the Gold plans have more generous benefits.

• Consumers who do not receive tax credits to help pay their premiums have other plan options that do not include the surcharge. These consumers can avoid paying the surcharge by switching to a different Bronze, Gold, or Platinum plan or purchasing a nearly identical Silver plan outside of Covered California that does not include the surcharge. Covered California required all health insurers to sell a plan outside of the marketplace that is nearly identical to the Covered California Silver plans, but without the additional premium cost to assist consumers in getting the most affordable plan possible.

Covered California’s Shop and Compare tool helps consumers compare their coverage options for 2018. Consumers will see the rates for the plans available to them in their area and find out if they qualify for financial assistance to help them pay for their coverage. The Shop and Compare tool is available at www.coveredca.com. Shopping around is really important and can help keep your coverage affordable.

For 2018, only two of the 11 health insurance companies changed their service regions. Anthem Blue Cross is withdrawing from 16 of California’s 19 pricing regions and Health Net is removing its HMO from a few regions. This means consumers who had these plans will need to shop for a new plan or they will be defaulted into a comparable cost plan.

It is best if you choose a new plan by mid-November. Covered California should have already sent you information about your new options and how to switch. If you do not choose a new plan by mid-November, Covered California will place you in a new plan to avoid a gap in coverage. The plan Covered California chooses will have the same benefits and similar copays as your current plan, but may not have the same provider network or formulary. If you do not like your new plan, you can switch to a different plan before January 31, 2018.

California is also providing some limited “continuity of care” protections for consumers who are forced to pick a new plan due to their existing plan leaving the region. Continuity of care means you may be able to pay in-network rates to see an out-of-network former provider. If your current provider is not covered under your new plan and you have an acute or serious chronic condition, including HIV and hepatitis C, your new health insurance plan may be able to work with your current provider while you are finishing treatment. For more information, visit www.coveredca.com/transitions-faqs.

People living with HIV should check plan formularies to ensure their drugs for HIV and other conditions are covered and accessible. There are some plans that should be avoided by people living with HIV because their drug formulary is inadequate. People living with HIV should also check with their doctor to make sure they accept the Covered California plan the person is considering.

There are also programs available to people living with HIV that can help make coverage more affordable. The AIDS Drug Assistance Program (ADAP) pays prescription deductibles and copays for medications on the ADAP formulary. In addition, the Office of AIDS Health Insurance Premium Payment Program (OA-HIPP) pays monthly health insurance premiums and outpatient medical out-of-pocket costs. OA-HIPP also covers dental and vision plan premiums. People living with HIV may qualify for these programs if their annual income is below 500% of the federal poverty level. To find the nearest enrollment site for these programs, call 1-844-550-3944.

People living with hepatitis C should check plan formularies to ensure their drugs are covered and accessible regardless of fibrosis stage. People living with hepatitis C should also make sure the cost-sharing is affordable before enrolling in a new plan. Drug companies have patient assistance programs that may help lower the cost of your hepatitis C drugs. More information about these programs can be found at www.fairpricingcoalition.org/projects. Be aware that Kaiser and some other pharmacies don’t currently accept copay cards, but you should be able to get reimbursed by the program if you can afford to pay for your medications upfront. Kaiser also has its own medical assistance program that serves people with incomes below 350% of the federal poverty level. ADAP covers hepatitis C drugs for all qualified individuals who are co-infected with HIV regardless of disease state or other considerations. However, it only covers a one- time course of treatment for hepatitis C under most circumstances. People who are co-infected qualify for ADAP and OA-HIPP if their annual income is below 500% of the federal poverty level.

All Covered California health plans cover Truvada^®, which is currently the only medication approved for PrEP. Prescription copays and other out-of-pocket costs, however, can make PrEP unaffordable for many individuals. The first thing you should consider is which metal tier is best for you. While Bronze plans have lower premiums, their high deductibles and out-of-pocket costs could make accessing PrEP unaffordable.

Once you have selected the appropriate plan, there are several copay programs available to help lower the cost of PrEP. Gilead, the pharmaceutical company that makes Truvada®, has a copay program that will cover up to $3,600 annually. Information about the copay program can be found at www.gileadcopay.com. Patient Access Network and Patient Advocate Foundation also have patient assistance programs for PrEP. More information about these programs can be found at www.fairpricingcoalition.org/projects. Be aware that Kaiser and some other pharmacies don’t currently accept copay cards, but you should still be able to get reimbursed by the copay program if you can afford to pay for your medications upfront. Kaiser also has its own medical assistance program that can help people with incomes below 350% of the federal poverty level.

The California Department of Public Health is currently developing a statewide PrEP

Assistance Program. For individuals with health insurance, the program will cover PrEP- related medical copays, coinsurance, deductibles, and drug costs not covered by the individual’s health insurance plan or Gilead’s copay assistance program. For uninsured individuals, the program will cover PrEP-related medical costs only (uninsured individuals can get free PrEP medication from Gilead’s patient assistance program). You may qualify for California’s PrEP Assistance Program if your annual income is below 500% of the federal poverty level. Implementation of this program for those who are uninsured is scheduled to begin in early 2018, but coverage for individuals with health insurance is not scheduled to become available until spring 2018.

There are numerous resources available to assist consumers with questions:

• Covered California’s Service Center: 1-800-300-1506
• Covered California’s website: www.coveredca.com
• Local, free, and confidential help is also available from one of Covered California’s 14,000 certified agents and enrollers. Consumers can find local help by visiting www.coveredca.com/get-help/
• Health Consumer Alliance offers free help if you have concerns about your health insurance company or access to medical care: 1-888-804-3536 or www. healthconsumer.org

If you’re living with HIV, you should seek assistance from someone knowledgeable about HIV programs and how they interact with Covered California. If you are unable to find an HIV-experienced certified agent or enroller, consult with an HIV case manager or benefits counselor. If you qualify for ADAP and OA-HIPP, you can find the nearest enrollment site by calling 1-844-550-3944.

If you’re considering PrEP, you can chat with a knowledgeable PrEP navigator at www.pleaseprepme.org. This website also contains a statewide directory of doctors with experience providing PrEP.