Covered California & People Living with HIV/AIDS Ryan White Cross Parts Meeting – 9/3/14 Anand 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 ProgramEligibility Requirements ADAP FAGI < $50k, Medi-Cal ineligible OA-HIPP Enrolled in ADAP Medi-Cal MAGI < 138% FPL Covered CA Income >138% FPL; subsidies up to 400% FPL (pro-rated)

Drug Formularies  Download at: drugs/ 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

Of the 35 antivirals in ADAP formulary… Insurance Carrier# of drugs covered Anthem Blue Cross28 Blue Shield28 Chinese Community Health Plan30 Health Net32 Kaiser Permanente31 LA Care Health Plan31 Molina Healthcare31 Sharp Health Plan32 Valley Health Plan31 Western Health Advantage22 *Medi-Cal31

Calculating Yearly Costs ItemPer unit/useYearly total Premium$377/month$4524 Premium assistance(-$314/month)(-$3768) Brand drug deductible$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$500Let’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 ItemBronzeSilver*Enhanced Silver GoldPlatinum Net premium$1$200$70$150$200 Deductible$5000$2000$500$0 PCP visit$60$45$15$30$20 Specialty visit$70$65$20$50$40 Labs30%$45$15$30$20 Brand drugs$50 $15$50$15 Generic drugs$15 $5$15$5 Hospitalization30%20%15%$600/day$250/day ER copay30%$250$75$250$150 Maximum out- of-pocket $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, Download from:

Covered CA + OA-HIPP  Timelines: before/after 15 th of month  Submit January 10  effective March 1  Submit January 20  effective April 1

Covered CA + OA-HIPP  Payments  Initial covers 1 st 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 1 st month’s premium and request refund from insurance plan after insurance plan receives initial payment

Questions?  Anand Kalra   , ex. 305

Thank you!