In the state of Indiana, there are several types of health insurance coverage and government supported assistance programs. These programs vary by state and can be navigated with you by your care coordinator.
The first and most traditional insurance is that offered by a company or a business to their employees. In general, only the employee, spouse, and children are eligible for this type of insurance coverage. There are many programs and each has different benefits available. Most companies require the employee to pay a portion of the insurance premium. Most insurance policies have what is called "in-network" or "primary care providers." It is very important to know if your insurance has such a requirement because the insurance company may not pay for a visit or for labs if the doctor and/or hospital are not in-network providers. Or, the insurance company may pay at a lower rate leaving you to pay the rest of the bill. Many insurance companies also have in-network pharmacy providers for medications. Many insurance policies offered by employers have a pre-existing condition clause. This means that any health condition diagnosis (such as HIV or AIDS) may likely not be covered under the policy for a certain number of days or months.
By law, an employer cannot refuse insurance coverage to any employee who is covered by the group plan and meets the eligibility requirements. In other words, an employee cannot be denied insurance coverage by a group plan based on a pre-existing health condition such as HIV. An employer also cannot require an employee to pay an increased rate for insurance based on a pre-existing condition. All employees are expected to pay the same amount of money for the same type of coverage.
If you leave your job, you may be able to continue your health insurance under what is called "COBRA" coverage. COBRA allows for you to continue health insurance for a specific number of months. However, you will be expected to pay the full amount of the monthly premium. If you do not pay the premium on time, this insurance can be cancelled.
The second type of insurance offered in the state of Indiana is called Medicaid or a sub-program of Medicaid called Hoosier Healthwise. These are government funded programs that provide health insurance to U.S. citizens who are residents of the state of Indiana. Each state has its own program, so if you live outside Indiana you will need to explore similar programs in your home area.You must meet income guidelines in order to receive benefits from such programs. Medicaid is offered primarily to pregnant women and children or those who are deemed by the state's definition to be disabled.Your social worker or care coordinator can help guide you through the application process if you qualify for these programs. There are many different Medicaid plans and many of them require that you choose a doctor who is your primary care provider (PCP). This type of system requires that you obtain a referral to a specialist including the person who treats HIV. If you do not follow the system and obtain the appropriate referrals, we may not be allowed to continue providing care to you or your child. If you do not choose your own primary care provider, one will be assigned to you through the Medicaid office.
Once a year, you will receive paperwork from the Medicaid office that will need to be completed on time to continue receiving Medicaid coverage. Otherwise, there may be a period of time when you or your child will not be able to obtain medications. It is important to remember that taking the antiretroviral medications less than 100% of the time may allow the virus to become resistant to the medications.
Approximately half of children infected with HIV at birth will have a condition called encephalopathy. This condition affects the brain and can lead to learning disabilities and/or some form of cerebral palsy (CP). One type of Medicaid coverage that provides additional benefits under such circumstances is called Medicaid Disability. A patient must be able to provide medical documents that prove that he or she is disabled and that this disability affects the ability to care for themselves. The care coordinator can help determine if you qualify for this type of coverage.
Children with Special Health care Needs (CSHCN)
Another program that may be available to children is called Children with Special Health care Needs (CSHCN). This is a program that can help pay for medical care of children with chronic medical conditions. Although the diagnosis of HIV does not by itself qualify a child for such assistance, associated issues such as developmental delay may. In order to be eligible, you must be a U.S. citizen, resident of the state providing the program, and you must meet medical and financial guidelines. The income guidelines are higher than those for Medicaid. There is a CSHCN office in the hospital that can help you through this process.
Children who have disabilities related to the diagnosis of HIV may be eligible for expanded programs through the Medicaid system. The Medicaid Waiver provides money for certain types of equipment and other services that may not be covered under other health insurance plans. This waiver program is not income dependent but there is a waiting list to get on the program. The Indiana Area Council on Aging is responsible for managing this program as well as a program called CHOICE. The CHOICE program can provide respite or relief services to families who meet the income guidelines.
Your child may also qualify for Social Security benefits or SSI if they meet certain disability guidelines and if the family meets income requirements. This program provides money to the household to help pay living expenses.
For those families that do not qualify for Medicaid and/or CSHCN, parents may purchase private health insurance, which is usually quite expensive and may not be available to those who have been diagnosed with HIV/AIDS. One such program is Indiana Comprehensive Health Insurance (ICHIA). This is a health insurance plan that is available in our state for people who cannot obtain health insurance from any other source and who do not qualify for Medicaid. Although it may be expensive to buy, it is certainly less expensive than paying for health care and medications out of pocket.
For those patients who live in Marion County in Indiana, there is a program through Wishard Hospital called Wishard Advantage. This program is for people who cannot afford private insurance and who do not qualify for Medicaid who meet the eligibility requirements. It is available to people who are not citizens of the United States.
The HIV Medical Services Program is a program that provides health care to people who are HIV+ and who meet eligibility requirements. This is a program for people who do not and cannot receive private insurance benefits and who do not qualify for Medicaid. In order to be considered for this program you must:
- have applied for Medicaid and received a denial for this program
- be a resident of Indiana for 365 straight days
- meet income guidelines.
This program is administered by the Indiana State Department of Health. Applications may be obtained through your care coordination site. This program also requires that you apply to ICHIA. Once you are approved for this program, you will have a 90 day pre-existing condition period. This means that the program will pay for all medical care except that related to HIV for that time. During this period, you will receive medication from the AIDS Drug Assistance Program (ADAP) which is a program that is supported by the drug companies that make the medications.You will also receive limited health care services through the Early Intervention Plan (EIP). After 90 days, all health care will be provided through the Health Insurance Assistance Plan, including the care for HIV. The ADAP and EIP programs will be discontinued.
This information may seem overwhelming and like a maze, but it is extremely important that coverage is in place to avoid any interruptions in medication delivery. Your care coordinator can help you sort through the various programs in order to determine the ones that will best fit your family's needs and those for which your family will qualify.