Transcript Redefining the Standard with Transgender

Covered California & People
Living with HIV/AIDS
Anand Kalra
Ryan White Cross Parts Meeting – 9/3/14
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Anthem Blue Cross
Blue Shield
Chinese Community Health Plan
Health Net
Kaiser Permanente
LA Care Health Plan
Molina Healthcare
Sharp Health Plan
Valley Health Plan
Western Health Advantage
Program Eligibility
Program
ADAP
OA-HIPP
Medi-Cal
Covered CA
Eligibility Requirements
FAGI < $50k,
Medi-Cal ineligible
Enrolled in ADAP
MAGI < 138% FPL
Income >138% FPL; subsidies up to
400% FPL (pro-rated)
Drug Formularies



Download at:
https://www.coveredca.com/faqs/prescriptiondrugs/
Formularies the same for each “metal tier”
(gold, silver, etc.) for a given insurer
Difference is deductible and copays.
Covered CA plans –
formulary analysis
Number of Covered CA plans that cover antiviral drugs listed in ADAP Formulary
ziagen
epzicom
trizivir
rescriptor
videx, videx ec
sustiva
emtriva
epivir
zerit
viread
truvada
hivid
retrovir
combivir
intelence
viramune
edurant
fuzeon
stribild
atripla
complera
agenerase
reyataz
prezista
lexiva
crixivan
kaletra
viracept
norvir
fortovase
invirase
aptivus
selzentry
isentress
tivicay
10
10
10
9
10
10
9
10
9
10
10
0
9
8
10
10
9
10
7
9
7
0
10
10
10
9
10
9
10
0
9
9
10
10
4
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
For a 35-year-old living in San Francisco who makes $17,000, takes 4 brand
drugs and 2 generics, filled 4x yearly
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
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 outof-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
January 10  effective March 1
 Submit January 20  effective April 1
 Submit
Covered CA + OA-HIPP

Payments
covers 1st month of insurance + 3 more
 Subsequent payments quarterly
 Initial

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
 [email protected]
 415-865-0176, ex. 305

Thank you!