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Does Health Insurance Cover HIV Treatment?

Though a diagnosis of HIV is scary already, added to that is the uncertainty over insurance. The medications and clinical treatment methods for HIV can be very expensive and require daily attention, all of which can add up quickly. Fortunately, insurance covers most HIV treatment. However, there are situations when the health insurance may not cover the HIV treatment as well.

  1. Pre-Existing Conditions

    • For those who already have health insurance at the time of the diagnosis, there is usually no problem. For those who do not, coverage could be denied under a "pre-existing condition" policy. States such as Florida, New Jersey, New York and California make it illegal to deny a group health insurance policy to someone with a pre-existing condition.

    Prescription Drug Coverage

    • For those with a prescription drug component, this should also be covered under the policy. The insurance company cannot deny a patient medically-necessary drugs simply because the patient is HIV positive. However, the insurance company may not pay as much for brand name drugs as it will for generics. If this is the policy, it must be enforced on all policies, not just those for clients with HIV.

    Lifetime Maximums

    • Though many people will never come close to their lifetime maximums on a health insurance policy, those with HIV may challenge that limit, usually set at $1 million or $2 million. That is one more way that insurance companies may eventually deny coverage. However, even with HIV, which can be controlled to a great extent through drug therapy, reaching lifetime maximums is rare (see resources below).

    Losing a Job

    • If an HIV patient loses a job, his or her health insurance coverage could also be threatened. A federal law known as COBRA guarantees patients can keep health insurance for up to 18 months after leaving their employment, but they are responsible for the full cost of premiums. However, this is a way to ensure coverage for treatment.

    Experimental Treatments

    • Treatments that are not designated by the FDA as approved treatments for a condition may be denied as claims. These are referred to as experimental treatments and insurance companies are not required to pay for such treatments. Though they may represent the only hope for some people, the cost of the treatment is up to the individual.

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