Covered California & People Living with HIV/AIDS

Ryan White Cross Parts Meeting – 9/3/14Anand Kalra

About me

Health Programs Administrator at

Transgender Law Center not a lawyer, not a doctor, just your friendly

neighborhood librarian Covered California Certified Educator and

Certified Enrollment Counselor

Covered California Premiums

By law, can only vary by: Age Location (19 regions)

Premium assistance available to households with income <400% FPL For 2014, ~$47,000 for individual, $96,000 for

family of four Amount of premium assistance (subsidy)

inversely proportional to income Higher income less assistance

Insurers with QHPs in CC

1. Anthem Blue Cross

2. Blue Shield

3. Chinese Community Health Plan

4. Health Net

5. Kaiser Permanente

6. LA Care Health Plan

7. Molina Healthcare

8. Sharp Health Plan

9. Valley Health Plan

10. Western Health Advantage

Program Eligibility

Program Eligibility Requirements

ADAPFAGI < $50k, Medi-Cal ineligible

OA-HIPPEnrolled in ADAP

Medi-CalMAGI < 138% FPL

Covered CAIncome >138% FPL; subsidies up to 400% FPL (pro-rated)

Drug Formularies

Download at: https://www.coveredca.com/faqs/prescription-drugs/

Formularies the same for each “metal tier” (gold, silver, etc.) for a given insurer

Difference is deductible and copays.

Covered CA plans –formulary analysis

ziagen

trizivir

videx, videx ec

emtriva

zerit

truvada

retrovir

intelence

edurant

stribild

complera

reyataz

lexiva

kaletra

norvir

invirase

selzentry

tivicay

101010

91010

910

91010

09

81010

910

79

70

101010

910

910

099

1010

4

Number of Covered CA plans that cover antiviral drugs listed in ADAP Formulary

Of the 35 antivirals in ADAP formulary…

Insurance Carrier # of drugs covered

Anthem Blue Cross 28

Blue Shield 28

Chinese Community Health Plan 30

Health Net 32

Kaiser Permanente 31

LA Care Health Plan 31

Molina Healthcare 31

Sharp Health Plan 32

Valley Health Plan 31

Western Health Advantage 22

*Medi-Cal 31

Calculating Yearly Costs

Item Per unit/use Yearly total

Premium $377/month $4524

Premium assistance (-$314/month) (-$3768)

Brand drug deductible

$50 $50

Brand drug copay $15/drug $240

Generic drug copay $5 $40

Primary care visit $0/first, $15 subsq. $30

Labs $15/visit $30

Medical deductible $500 Let’s assume 0

Total $1146

For a 35-year-old living in San Francisco who makes $17,000, takes 4 brand drugs and 2 generics, filled 4x yearly

Calculating Yearly Costs

Item Bronze Silver* Enhanced Silver

Gold Platinum

Net premium

$1 $200 $70 $150 $200

Deductible $5000 $2000 $500 $0 $0

PCP visit $60 $45 $15 $30 $20

Specialty visit

$70 $65 $20 $50 $40

Labs 30% $45 $15 $30 $20

Brand drugs $50 $50 $15 $50 $15

Generic drugs

$15 $15 $5 $15 $5

Hospitalization

30% 20% 15% $600/day $250/day

ER copay 30% $250 $75 $250 $150

Maximum out-of-pocket

$6250 $6250 $2250 $6250 $4000

Bold = subject to deductibles * Regular silver for income >250% FPL; subsidy rates are lower as income increases; this is for $30,000

Covered CA + OA-HIPP

Source: California HIV/AIDS Policy Research Centers, Policy Brief – Sept. 2013

Covered CA + OA-HIPP

Application for OA-HIPP should include OA-HIPP Application Insurance Assistance Section Consent Form Insurance Assistance Section ARIES Consent Billing statement from Covered California plan Covered California Welcome Letter

Not needed if billing statement includes premium assistance amount

Source: Office of Aids Insurance Assistance Section Memo - OA-HIPP/Covered California Policy and Procedures, December 3, 2013; and Memo - OA-HIPP- Enrolling Clients into OA-HIPP after Obtaining Coverage Through Covered California, February 14, 2014. Download from: http://www.cdph.ca.gov/programs/aids/Pages/OAIAS.aspx

Covered CA + OA-HIPP

Timelines: before/after 15th of month Submit January 10 effective March 1 Submit January 20 effective April 1

Covered CA + OA-HIPP

Payments Initial covers 1st month of insurance + 3 more Subsequent payments quarterly

First month’s premium: If applying for insurance to start before OA

processing time, patient can pay the 1st month’s premium and request refund from insurance plan after insurance plan receives initial payment

Questions?

Anand Kalra anand@transgenderlawcenter.org 415-865-0176, ex. 305

Thank you!