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CONSUMERS: HIV/AIDS (California)
http://www.insurance.ca.gov/0100-consumers/0100-insurance-guides/0500-health-series/hiv-aids.cfm
Since the first diagnosed case of HIV/AIDS over twenty years
ago, there have been many remarkable advances in treating the
disease. The life expectancy for many people living with
HIV/AIDS has increased dramatically. The continuing hope is that
medical science will find a cure for HIV/AIDS or at least be
able to develop treatment therapies that cause the disease to be
treated as a chronic condition.
While
public attitudes regarding HIV/AIDS have changed for the better
because of education and exposure, many of the concerns
surrounding HIV/AIDS diagnosis and treatment remain the same.
The cost of life-saving drugs and treatment regimens are still
very expensive. Also, people living with HIV/AIDS often face
discrimination because of ignorance about the disease.
The
California Department of Insurance (CDI) believes that it is
crucial for people living with HIV/AIDS to know their insurance
rights. Being informed of your insurance rights can help you
take charge of your future and allow you to effectively manage
HIV/AIDS. This brochure discusses the most common HIV/AIDS
insurance issues regarding health, life, and disability income
insurance.
When applying for health insurance, an insurance company may ask
questions regarding your medical history to help determine
coverage eligibility. Medical records from your physician(s) may
be requested as part of the underwriting process. Insurance
companies rely upon accurate information to make their
underwriting decisions. If the insurance company discovers that
you did not accurately report your medical history on the
application, your policy can be cancelled or rescinded.
A health
insurance company cannot require you to disclose your HIV status
or to take an HIV test as part of the application process (see
California Insurance Code [CIC] Section 799.09). However, it can
ask if you have received medical treatment for AIDS,
AIDS-related complex (ARC), or an immune system disorder other
than HIV/AIDS. It may also ask you if you are taking or have
taken HIV/AIDS medications. Since HIV infection is not a
diagnosis of AIDS or ARC, a health insurer cannot deny
health coverage soley because an applicant is HIV positive. If
an applicant has been treated for AIDS or ARC, a health insurer
can deny coverage based on a preexisting medical
condition. CIC Section 10291.5(c)(2) requires that all
applications for health insurance (excluding guaranteed issue)
prominently display the following notice: "California law
prohibits an HIV test from being required or used by health
insurance companies as a condition of obtaining health insurance
coverage."
If your
application for health insurance is declined, you may request
the specific reasons for the declination in writing. It is
important to remember that an insurance company cannot refuse an
application for coverage on the basis of an applicant’s race,
color, religion, national origin, ancestry, or sexual
orientation, nor can they charge higher premiums based on these
criteria.
If you have been turned down for health insurance because of a
preexisting condition (such as treatment for AIDS or ARC), you
may want to consider the following options in an effort to
obtain health insurance and/or drug therapy assistance:
Medical underwriting rules for small group health insurance
(2-50 people) differ from large group and individual health
insurance policies. Regardless of any preexisting condition, you
must be offered coverage under a small group policy on a
guaranteed issue basis. The application may still contain health
questions and a request for medical records or past medical
history. If you can gain employment with a small employer who
offers small group health insurance, then you must be accepted
onto the plan. However, the small group insurance company can
utilize a six-month waiting period for preexisting conditions.
If you have prior group health insurance (creditable coverage)
without a break of more than 180 days, it must be applied to
decrease or eliminate the waiting period. For a complete
discussion of creditable coverage and waiting periods for
individual and group health insurance coverage (both small and
large group), please review the CDI Health Insurance
brochure. Contact information for the CDI is located in the
"Talk To Us" section of this brochure.
The Major Risk Medical Insurance Program (MRMIP) offers limited
health insurance benefits to California residents who are unable
to purchase health insurance due to a preexisting medical
condition. If you have a preexisting condition and are not
eligible for COBRA, Cal-COBRA, or HIPAA, then you can apply to
MRMIP as a last resort to obtain health coverage. (COBRA,
Cal-COBRA, and HIPAA are discussed later in this brochure.) This
program provides health care coverage through contracted health
insurance companies and health plans. MRMIP is partially
subsidized; however, qualifying participants must pay a portion
of the premium, which can be costly. MRMIP is under the
jurisdiction of the Managed Risk Medical Insurance Board
(MRMIB). Please see the "Resources" section of this brochure for
MRMIB contact information.
The California Department of Health Services (DHS) oversees the
Medi-Cal program. Medi-Cal is California’s Medicaid health care
program and is supported by federal and state tax dollars. This
program pays for a variety of medical services for people with
limited income and resources and/or disabled individuals
regardless of any preexisting
health
condition. If you are eligible, you can receive Medi-Cal
benefits as long as you continue to meet the eligibility
requirements. Medi-Cal is managed through your local county
welfare/social services department. Contact your county
welfare/social services department for current eligibility
information or see the "Resources" section under DHS for related
Medi-Cal contacts.
The DHS also operates the Office of AIDS for California
residents. The Office of AIDS creates educational materials and
compiles statistical information regarding HIV/AIDS. Their
efforts target publicly-funded HIV/AIDS care and treatment
programs and critical prevention strategies aimed to interrupt
HIV/AIDS transmission. The AIDS Drug Assistance Program (ADAP)
falls under the control of the Office of AIDS.
The ADAP
was established in 1987 to help provide HIV/AIDS drug therapy
access to individuals who are uninsured or underinsured of
low-to-moderate income levels. ADAP is a state prescription drug
program that is jointly funded by Ryan White CARE legislation
and state funds. The goal of the ADAP is to make available drug
treatments that can reliably be expected to increase the
duration and quality of life for those living with HIV/AIDS. For
ADAP eligibility requirements, please refer to the "Resources"
section for contact information.
Since the onset of HIV/AIDS, many private clinics and support
organizations have been created that provide services to people
living with HIV/AIDS. These clinics and organizations can be an
excellent source of information on a variety of HIV/AIDS related
issues, including access to health care. Some private clinics
provide basic health care services to HIV/AIDS patients and can
provide contact information for drug trials and experimental
treatment protocols that can sometimes provide complete medical
services for qualified study participants. Please see the
"Resources" section for a list of California
When you are covered under a group health insurance policy from
your employer, you have certain rights under the Consolidated
Omnibus Budget Reconciliation Act (COBRA). COBRA is a federal
law that extends your current group health insurance when you
experience a qualifying event such as termination of employment
or reduction of hours to part-time status. By electing COBRA you
extend your current group coverage and maintain continuity of
care, which can be very crucial when undergoing treatment for
HIV/AIDS. The extension period for COBRA is 18 months and some
people with special qualifying events may be eligible for a
second 18-month extension.
To be
eligible for COBRA, your group policy must be in force with 20
or more employees currently covered by the employer’s group
health insurance policy. Indemnity policies, PPOs, HMOs, and
self-insured plans are eligible for COBRA extension; however,
federal government employee plans and church plans are exempt
from COBRA. Individual health insurance is also exempt from
COBRA, which may be an important reason to pursue participation
in an employer group health plan if one is available to you.
Cal-COBRA
is California law that closely tracks federal COBRA. With
Cal-COBRA, the group policy must be in force with 2-19 employees
currently covered. The extension for Cal-COBRA is 36 months.
Only indemnity policies, PPOs, and HMOs are eligible for
Cal-COBRA. As with COBRA, Cal-COBRA does not apply to individual
health insurance. For further discussion of Cal-COBRA, including
special provisions for seniors under Cal-COBRA, contact the CDI
by using the information provided in the "Talk to Us" section of
this brochure.
It is
important to note that healthcare jurisdiction in California is
divided between both state and federal agencies. COBRA is
regulated by the U.S. Department of Labor, Pension and Welfare
Benefits Administration (DOL-PWBA) and Cal-COBRA is jointly
regulated by the CDI and the California Department of Managed
Health Care (DMHC) depending upon what type of group coverage
you have (indemnity or HMO). These agencies can provide further
information on the time frames employers and insurance
companies/health plans must follow to offer COBRA or Cal-COBRA
extension coverage for eligible employees and their dependents.
If you
have questions or problems with COBRA or Cal-COBRA, you can
reach the appropriate state of federal agency by referencing the
contact information available in the "Resources" or "Talk to Us"
sections of this brochure. Also, you may wish to review the CDI
Health Insurance brochure for a more detailed explanation
of indemnity health insurance, HMOs, PPOs, and self-insured
health plans.
In 1996 the federal government passed into law the Health
Insurance Portability and Accountability Act (HIPAA). HIPAA law
provides eligible individuals who have recently lost their
employer-sponsored group health insurance the opportunity to
purchase health insurance coverage even if they have a
preexisting health condition, which includes treatment for AIDS
or ARC. If you meet the definition of an eligible individual,
all health insurance companies and health plans that sell
individual coverage must offer you health insurance regardless
of your medical history. This requirement to issue insurance is
called "guaranteed issue." In order to qualify as an eligible
individual, you must meet the following conditions:
Your last health care coverage must have been under an employer
sponsored group health plan, which includes COBRA or Cal-COBRA
continuation coverage, for at least 18 months. This prior
18-month coverage is referred to as "creditable coverage."
All available COBRA or Cal-COBRA continuation coverage has been
elected and exhausted. If you qualify for COBRA or Cal-COBRA you
are required to accept (elect) the coverage and continue the
coverage for the maximum time period allowed (exhaust the
coverage). (When an employer terminates its existing group
health plan entirely, COBRA or Cal-COBRA coverage ends and is
considered exhausted.)
You are not eligible under a group health plan, Medicare,
Medi-Cal, and /or do not have other health insurance coverage.
You did not lose your most recent health coverage due to
nonpayment of premium or fraud.
Once
COBRA or Cal-COBRA has been exhausted, you have 63 days to file
an application to purchase a guaranteed issue HIPAA policy with
an insurance company or health plan. All carriers that sell
individual health care policies must offer their two most
marketed individual plans to HIPAA eligible individuals. If you
accept a conversion policy or a short-term policy after
exhausting COBRA or Cal-COBRA, you give up your HIPAA
eligibility. It is important to understand that a conversion
policy is not a HIPAA policy.
Although
HIPAA is a federal law, as of January 1, 2001, the
responsibility for enforcing HIPAA (in regards to guaranteed
issue health insurance) within the state of California was
transferred to the CDI and the DMHC. Depending on the type of
coverage you have, you can contact either the CDI (indemnity) or
the DMHC (HMO) if you are experiencing problems securing a HIPAA
policy. Please see the contact information in the "Talk to Us"
or the "Resources" section of this brochure to reach either the
CDI or the DMHC regarding HIPAA questions.
The CIC provides consumer protection against several actions
that are considered unfair claims settlement practices on the
part of insurers. In the case of HIV/AIDS-related
hospital,
medical, or surgical claims, CIC Section 790.03(h)(16) states
that "delaying the payment of …[HIV/AIDS-related] benefits for
services provided …for more than 60 days after the insurer has
received a claim for those benefits, where the delay in claim
payment is for the purpose of investigating whether the
condition preexisted the coverage" is to be considered an unfair
claims settlement practice. It is important to note that the 60
days does not include any time that the insurer is waiting for
relevant medical information requested from a health care
provider.
If you
believe that an insurance company is involved in unfair claims
practices stemming from your HIV/AIDS status, or that you are
being mistreated in any way by your insurance company due to
your health status, then contact the CDI immediately through the
information provided in the "Talk to Us" section of this
brochure.
When you apply for a life or disability income insurance policy,
an insurance company can request a physical examination, which
may include an HIV antibody test. An insurance company that
requests you to take an HIV antibody test is required to get
your written informed consent to conduct the test. CIC Section
799.03 states that "written informed consent shall include a
description of the test to be performed, including its purpose,
potential uses, and limitations, the meaning of its results,
procedures for notifying the applicant of the results, and the
right to confidential treatment of the results." If you test
positive for HIV antibodies, the life or disability income
insurance company can deny your application for insurance. It
can also deny coverage if you refuse to provide your written
informed consent to take an HIV antibody test. The life or
disability income insurance company must pay for the cost of the
HIV antibody test.
Further
questions on life and disability income insurance concerning
HIV/AIDS related topics can be addressed by contacting the CDI
through the information provided in the "Talk to Us" section.
Also, for general information on life insurance, including
product descriptions and glossary, request the CDI Life
Insurance brochure when contacting us.
Viatical settlement purchasers buy life insurance policies that
are based on the lives of people with catastrophic or
life-threatening illnesses or conditions. If the policyholder
has heart disease, for example, the settlement may be considered
a viatical settlement. Selling your life insurance policy
provides you with a cash settlement that can be used in any way
you see fit. Even though a settlement is called a "life
settlement," or other names, it may still be considered a
"viatical settlement" under California law.
If you
are considering selling your life insurance policy to a viatical
settlement purchaser, you should contact your life insurance
company directly to determine if they offer an accelerated
benefit, a living death benefit, a loan, or cash value for the
policy. The terms and conditions offered by the insurance
company for these types of similar benefits may be better than
those offered by a viatical settlement purchaser. By comparing,
you may be able to receive a larger amount of money for your
life insurance policy.
People
who "enter into" or "solicit" viatical settlements from
policyholders must be licensed by the CDI. For example, a person
who assists an insured or policyholder in selling their policy,
a purchaser of the policy, and a person soliciting investments
in a viatical settlement transaction must all be licensed by the
CDI. Consumers should check the license status of the parties
involved with the CDI.
You can
contact the CDI by using the information in the "Talk to Us"
section to check whether the viatical settlement company or
individual you are dealing with is licensed. When contacting the
CDI, you can also request a copy of the Viatical Settlement
brochure that provides a more complete explanation of the
viatical settlement process.
Health, life, and disability income insurance can play a major
role for people living with HIV/AIDS. Knowing your insurance
rights and being able to properly utilize the coverage you have
can assist you in staying healthy and in maintaining the quality
of your life. The CDI is dedicated to people living with
HIV/AIDS and is available to answer any HIV/AIDS questions
relating to insurance. Please feel free to contact us by using
the information available in the "Talk to Us" section located on
the last page of this brochure.
AIDS Project Los Angeles (APLA)
3550 Wilshire Blvd., Suite 30
Los Angeles, CA 90010
Phone: 213-201-1600
Web Site:
www.apla.org
California
Association of Health Underwriters (CAHU)
P. O. Box 1071
Fresno, CA
93714
Phone:
800-322-5934
Web Site:
www.cahu.org
Department of Health Services
714/744 P Street
Sacramento, CA 95814
Phone: 916-445-4171
Web Site:
www.dhs.ca.gov
• Office of AIDS
611 North 7th Street
Sacramento, CA 95814
Phone: 916-445-0553
Web Site:
www.dhs.ca.gov/AIDS
•
AIDS Drug Assistance Program (ADAP)
Phone:
888-311-7632
Web Site:
www.ramsellcorp.com
• Medi-Cal
714/744 P Street
Sacramento, CA 95814
Phone: 916-657-2941
Web Site:
www.medi-cal.ca.gov
Contact Your Local County Social Services for
Eligibility
U.S.
Department of Labor
Pension and Welfare Benefits Administration (DOL-PWBA)
Northern California
71 Stevenson Street, Suite 915
P.O. Box 190250
San Francisco, CA 94119-2050
Phone: 415-975-4600
Phone: 866-275-7922
Southern
California
1055 E.
Colorado Blvd., Suite 200
Pasadena, CA
91106-2341
Phone:
626-229-1000
Phone: 866-275-7922
Web Site:
www.dol.gov/pwba/welcome.html
Publication Hotline: 800-998-7542
Department of Managed Health Care (DMHC)
980 Ninth Street, Suite 500
Sacramento,
CA 95814
Phone:
888-466-2219
Web Site:
www.dmhc.ca.gov
Managed Risk Medical Insurance Board (MRMIB)
Major Risk Medical Insurance Program (MRMIP)
P.O. Box 9044
Oxnard, CA
93031
Phone:
800-289-6574
Web Site:
www.mrmib.ca.gov
Minority AIDS Project (MAP)
5149 West Jefferson Blvd.
Los Angeles,
CA 90016
Phone:
323-936-4949
Web Site:
www.map-usa.org
San
Francisco
AIDS Foundation
995 Market Street, Suite 200
San
Francisco, CA 94103
Phone:
415-487-3000
TDD: 415-864-6606
Web Site:
www.sfaf.org
•
California HIV/AIDS Hotline
Phone: 800-367-2437
TDD: 888-225-2437
Creditable Coverage or
Prior Qualifying Coverage – A written statement
from your prior insurance company or health plan documenting the
length of time you were covered.
Coverage
– The scope of protection provided by an insurance contract
which includes any of the listed benefits in an insurance
policy.
Declination
– The rejection by an insurance company of an application for a
policy.
Experimental and/or Investigational Medical Services
– A drug, device, procedure, treatment plan, or other therapy
that is currently not within the accepted standards of medical
care. (Please contact the CDI for information on the Independent
Medical Review [IMR] program.)
Guaranteed Issue
– A health insurance policy that must be issued regardless of
any preexisting medical condition. The present and past physical
condition of a health insurance applicant is not considered as
part of underwriting. No physical examination is required. The
insurance company cannot decline coverage to an applicant of a
guaranteed issue policy based on medical history.
Policy
– The written contract between an individual or group
policyholder and an insurance company. The policy outlines the
duties, obligations, and responsibilities of both the
policyholder and the insurance company. A policy may include any
application, endorsement, certificate, or any other document
that can describe, limit, or exclude coverage benefits under the
policy.
Preexisting Condition
-- Any illness or health condition for which you have received
medical advice or treatment during the six months prior to
obtaining health insurance. Group healthcare policies cover
preexisting conditions after you have been insured for 6 months,
and individual policies cover preexisting conditions after you
have been insured for 1 year. Reference CIC Section 10198.7.
Recision
–The cancellation of an insurance policy back to its effective
date resulting in a return of all premium charged.
Underwrite
– The process to evaluate the insurance application and
independent sources in order to verify the information provided
and to determine the acceptability of the risk.
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