Gearing up for Open Enrollment: Accessing HIV/AIDS Care & Treatment through the ACA Marketplaces

By Amy Killelea June 5, 2013

Cross-posted from AIDS Education & Training Centers National Resource Center

October 1, 2013 – the date when the Affordable Care Act’s (ACA’s) marketplaces open for enrollment – is less than four months away, and there is much still be done to ensure a smooth transition to coverage through these marketplaces.  The marketplaces, which will allow people to compare and purchase “Qualified Health Plans” (QHPs), provide a tremendous opportunity for people living with HIV to access comprehensive, affordable private insurance – many for the first time. Maximizing access to private insurance will be particularly important in states that do not expand Medicaid in 2014. However, engaging with and navigating the private insurance options will involve new issues and concerns and a new insurance vocabulary. State HIV/AIDS programs, providers, and consumers are considering the following issues and action steps as they prepare for open enrollment:

1. How Will Clients Apply for Coverage through the Marketplaces?

When enrollment through the marketplaces opens in October, people will be able to apply for Medicaid coverage as well as federal premium tax credits and cost-sharing subsidies to purchase private insurance through a single streamlined application.  The initial open enrollment period will run from October to the end of March (in subsequent years, the open enrollment period will be shorter). The application will be available online (though a paper application will also available) and will collect eligibility information that, in most cases, will be instantly verified with federal data sources.

Income eligibility will be determined based on a person’s “Modified Adjusted Gross Income,” (MAGI) which will be determined using most recent federal tax information for most applicants (though pay stubs and other documentation of income are allowable in cases where the federal tax return does not accurately reflect current income).  People trained in ACA coverage options – including Patient Navigators and Certified Application Counselors – will be available to help people navigate the application process. Many AIDS Service Organizations and case managers are preparing to undergo ACA outreach and enrollment training to be able to help assist clients into new coverage options.

Action step: Ensure that case managers and other outreach and enrollment specialists are familiar with the streamlined application components and are engaged in ACA training programs.

2.     When Will Coverage Begin?

Coverage effective dates may vary by plan and it will be important for people enrolling in coverage as well as their providers to identify when coverage becomes effective as people transition.


QHP Through Exchange/Marketplace

90 day eligibility determination

Eligibility determination “promptly and without undue delay”

Continuous enrollment

Open enrollment during specified times (with special enrollment available for a set of specific circumstances)

Retroactive coverage up to 3 months prior to the date of application

Coverage begins:

•      If the plan selection is received by the exchange/marketplace on or before December 15, 2013, coverage begins January 1, 2014.

•      If the plan selection is between the 1st and 15th day of any subsequent month during open enrollment period, coverage begins the first day of the following month.

•      If the plan selection is received between the 16th and last day of the month, coverage begins the first day of the second following month.

Note: coverage date requirements are a federal floor; plans may begin coverage sooner than these dates.

Action step: Familiarize yourself with different coverage effective dates to ensure uninterrupted access to care

3.     How Will People Pick the Plan That Is Best for Them?

In the coming weeks, the plans that will be sold in the marketplaces will be reviewed and certified. These plans have to comply with ACA requirements, including coverage of Essential Health Benefits, adequate provider networks, and plan designs do not discriminate based on health status. Every marketplace will have a “plan finder” function, which will allow people to compare plans and to pick the one that meets care, treatment, and affordability needs.

Action step: As people living with HIV assess their plan options, they should consider the following:

  • Does the plan’s prescription drug formulary cover the client’s HIV treatment regimen or other medications the client may require (such as viral hepatitis treatment)?
  • Does the plan’s provider network include the client’s current HIV providers (including pharmacies)
  • Taking into account availability of premium tax credits and cost-sharing reductions, what are the remaining costs of coverage, including premiums, deductibles, co-payments, and co-insurance? Can ADAP insurance purchasing programs help with remaining costs in your state?
  • Are there limits on coverage or prior authorization requirements that could impact access to services?

Navigating the marketplace and ensuring that people living with HIV are able to access the coverage options that meet their care, treatment, and affordability needs will be challenging. However, the ACA offers an unprecedented opportunity to expand access to insurance for populations that have historically been shut out of the private insurance market, and HIV/AIDS programs, providers, and consumers are preparing to maximize this opportunity.