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HIV/AIDS
Introduction
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.
What You Need to Know About Health 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application, your policy can be cancelled or rescinded.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.
Health Insurance Options
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:
Small Group Insurance
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.
Major Risk Medical Insurance Program (MRMIP)
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.
Medi-Cal
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.
Office of AIDS and the AIDS Drug Assistance Program (ADAP)
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.
Private Clinics and HIV/AIDS Related Organizations
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 HIV/AIDS related
organizations.
COBRA and Cal-COBRA
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.
The Health Insurance Portability and Accountability Act
(HIPAA)
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.
Unfair Claims Practices
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.
What You Need to Know About Life and Disability Income
Insurance
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 and Life Insurance
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.
In Summary
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.
Resources
AIDS Project Los Angeles (APLA)
3550 Wilshire Blvd., Suite 30
Los Angeles, CA 90010
Phone: 213-201-1600
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
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Office of AIDS
611 North 7th Street
Sacramento, CA 95814
Phone: 916-445-0553
• 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
Glossary of Terms
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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