Personas con VIH o SIDA

Additional Drug and Monthly Premium Payment Assistance Programs

Individuals may be able to get help paying for their HIV or AIDS medications. The AIDS Drug Assistance Program (ADAP) within the California Department of Public Health helps ensure that eligible individuals living with HIV or AIDS who are uninsured and underinsured have access to life-saving HIV medications. An individual with a modified adjusted gross income (MAGI) up to 500 percent federal poverty level may qualify for ADAP. For ADAP eligibility information, including where to go to enroll, drug formulary lists and participating ADAP pharmacies and locations, please call (844) 421-7050.

ADAP can provide drug deductible and copay help for drugs on the ADAP formulary. In order for ADAP to assist individuals with these drug costs, their health insurance plan’s pharmacy must also be a participating ADAP pharmacy. A list of the antiretroviral (ARV) drugs that are available on the ADAP formulary, along with those available through the Covered California health insurance plans, is available as a downloadable PDF.

Qualified individuals enrolled in ADAP can also receive help paying Covered California monthly premiums through the Office of AIDS’ Health Insurance Premium Payment (OA-HIPP) program. Individuals enrolled in OA-HIPP may also get assistance with outpatient medical out-of-pocket costs.

If an individual and a third party, such as OA-HIPP, both paid the individual's premium for the same month, the individual may contact the health insurance company and request a refund. They may also contact the health insurance company for any other issues relating to premium payments.

Cómo mantener el mismo médico para los servicios

“Continuity of care” is the continuation of a care plan for a limited amount of time despite switching to a new health insurance plan or experiencing a change in the provider, hospital or pharmacy network of an individual's health insurance plan. Individuals in this situation may want to continue health care services with their previous doctor or hospital. To receive continuity-of-care services, consumers must contact their new health plan and request continuity of care. A consumer’s doctor or hospital also must agree to keep them as a patient.

Solo las personas con ciertos tipos de problemas o condiciones de salud pueden recibir atención de continuidad. El VIH y el SIDA pueden calificar como “enfermedades crónicas graves”, lo que permitiría un máximo de 12 meses de continuidad de la atención. Una lista completa de las circunstancias que califican está disponible en el sitio web del Departamento de Atención Médica Administrada.

If an individual thinks they might be eligible for continuity of care, they should contact their current Covered California health insurance plan and request it. Ultimately, a continuity-of-care request is between the consumer’s current health insurance plan and their previous doctor or hospital. If their health insurance plan denies their request for continuity of care or delays giving them an answer, they can file a formal grievance (also known as a complaint or appeal) with the health insurance company. If an individual's health insurance company does not resolve their grievance/complaint/appeal to their satisfaction, contact the California Department of Managed Health Care’s Help Center at (888) 466-2219 for help. If a consumer’s Covered California health insurance plan is a Health Net PPO plan, contact the California Department of Insurance at (800) 927-HELP (4357).

Note: Covered California does not decide on continuity-of-care requests. Additional continuity-of-care information related to health insurance plans regulated by the Department of Managed Health Care can be found on the Department of Managed Health Care website. For free, confidential and local help with grievance process, contact the Health Consumer Alliance at (888) 804-3536 or visit www.healthconsumer.org.

Mantener las mismas drogas y medicamentos

If an individual enrolls in a Covered California health insurance plan, their new plan may cover any drugs and medications they were taking before enrolling, but this depends on many factors. Also, the list of drugs (also known as the formulary) that Covered California health plans cover may periodically change. If an individual has questions or concerns about their access to a particular medication, they should first contact their health insurance plan directly and request that medication. If their request is denied, they should file a formal grievance (also known as a complaint or appeal) with the health insurance plan. If their health insurance plan does not resolve their grievance, complaint or appeal to their satisfaction, contact the California Department of Managed Health Care’s Help Center at (888) 466-2219 for help. If an individual's Covered California health insurance plan is a Health Net PPO plan, contact the California Department of Insurance at (800) 927-HELP (4357). If they need medications urgently and their health insurance plan is not responding, consumers can also contact the Department of Managed Health Care or the California Department of Insurance for help.

For free, confidential and local help with the grievance process, contact the Health Consumer Alliance at (888) 804-3536 or visit www.healthconsumer.org.

Servicios y recursos adicionales

Las personas que viven con VIH y SIDA podrían ser elegibles para recibir servicios adicionales financiados a través del Programa Ryan White, que incluyen administración de casos, apoyo nutricional, transporte y servicios legales gratuitos. Comunícate con la Oficina de SIDA del Departamento de Salud Pública de California al (916) 449-5900 para obtener más información.

Hay disponible asistencia gratuita, confidencial y local

Working through payment issues, medication requests, continuity of care and other issues can be difficult. Covered California has made available free, confidential and local assistance to all enrollees. The Health Consumer Alliance can help enrollees work with their health insurance company and, if necessary, work with health insurance regulators. Call (888) 804-3536 or visit www.healthconsumer.org.