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Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
Information about all aspects of health care from choosing a doctor and treatment, staying safe in a hospital, to end of life care. Includes how to obtain, choose and maximize health insurance policies.
Answers to your practical questions such as how to travel safely despite your health condition, how to avoid getting infected by a pet, and what to say or not say to an insurance company.

Health Plan Evaluator - HIV/AIDS

Related Article: Health Plan Evaluator

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Patients have better results with a qualified, board certified doctor with experience in HIV. It's important you have a doctor you can communicate with, who shares the same philosophy in treating HIV, and who will respect your end of life wishes.
Research shows that patients of doctors trained and experienced with your particular cancer have better results.
Patients have better results if treated in a high quality hospital with experience with HIV.
Patients with an HIV specialist do better than people not treated by an HIV specialist. The referral process to a specialist may vary greatly from plan to plan. Some managed care plans require a referral from your primary care physician for each visit. An open/standing referral is preferable.
It is important to be able to get a second opinion whenever you want one. It is preferable to get a second opinion if there is bad or unexpectedly good medical news. If the first and second opinions differ, a third opinion is preferable.
Whether cost of your health care is an issue for you likely depends on your financial situation. For most people it is very important. When considering the amount of the premium, also add in other expenses for which you will be reponsible such as deductible, co-insurance and co-pays.
It is likely that a person who is HIV positive will use up the annual deductible each year in medical expense (including visits to medical providers and tests.)
To get a fix on how important coinsurance is to you, try to estimate the number of times you will visit a doctor or other health care provider during the coming year. Last year's visits may be a good indicator. At least it will be a starting point.
To get a fix on how important co-payments are to you, try to estimate the number of times you will visit a doctor or other health care provider during the coming year. Last year's visits may be a good indicator. At least it will be a starting point. While co-payments are small, they can add up quickly.
The lower the annual cap, the less you have to pay out of pocket if your medical expenses add up. Just paying co-pays for seeing a medical provider can add up quickly with HIV.
When thinking about your priorities with respect to handling billing paperwork, consider that until there's a cure, you are likely to live with HIV for the rest of a hopefully long life. Perhaps you have a system in place that's easy for you to keep to date. Perhaps you have a friend who can take over this chore for you. Professional help is available.
A high lifetime maximum is essential for people with HIV. HIV treatments and medications can be very expensive.
Complementary therapies are steadily becoming an integral part of the American medical arsenal, particularly for people with HIV.
Long term use of HIV drugs can cause expensive oral conditions.
HIV drugs can be very expensive, particularly the newer ones. Some drugs cost thousands of dollar a month, and many people with HIV need more than one of them.
A diagnosis of HIV does not generally increase the likelihood of requiring drug or alcohol treatment. Although the odds are slight, it is possible that pain medication can lead to an addiction. This coverage may also be important if you have a personal or family history of drug or alcohol problems.
If durable medical equipment is not important for HIV, it may be for HIV related conditions.
If currently approved HIV drugs stop working for you, you may want to try experimental drugs that show promise. The costs of a clinical trial are assumed by the sponsors of the trial.However, trials may not cover the general medical costs that accompany them.
With HIV, there can be times when home health care is essential.
Most people prefer to have end-of-life treatment at home. Facility care coverage is crucial if you do not have someone at home to be a primary care provider.
Hospitalizations for HIV and/or HIV related conditions can be lengthy and very expensive.
A large percentage of people with HIV suffer from major depression that may require treatment with counseling and medication. Several HIV experts with whom we have spoken suggest that a person with HIV expect periodic bouts of depression.
Living with HIV does not generally increase the likelihood of your needing inpatient mental health services. However, a personal or family history of mental health problems may.
In general, HIV no longer prevents you from obtaining a transplant.
Patient assistance programs can take a lot of the guesswork out of living with HIV. Services include an expert to call who gets to know you and your situation. You can call with questions before or after doctor appointments, before, during or after treatments, or you can call with general questions about your health care.
Experience shows that HIV can take a turn at any time requiring expensive medical care. It is preferable not to go any period of time without health insurance.
It is likely that you are receiving preventive treatment as part of your ongoing health care. If not, preventive treatments are preferable. Hard as it may be to think about, you could be hit with another health condition. Preventive health care is also important for everyone who may be covered by your policy (if any).
Reconstructive surgery is not generally required by people with HIV. However, it may possibly be needed due to an HIV related condition - or a totally unrelated condition. Check with your doctor if you have questions. Also check your family history to see if you have a genetic predisposition to a health condition which could require this type of procedure.
Rehabilitation therapy may be required because of HIV related conditions as well as due to possible effects of HIV.
Right to renew is important because it may be difficult for a person who is positive to obtain new health insurance. There is also the possiblity that if you have to purchase new health insurance, you may be subjected to a period of time during which your HIV and other existing medical conditions aren't covered.
Although there may be some foreign countries you are not supposed to enter, HIV does not prevent people from traveling. If you do travel, heath coverage is essential. To learn more, see: Travel
It's difficult to learn how well a plan operates and how well it treats its insureds. Independent ratings give a reasoned idea of what to expect. Participation in most ratings is voluntary. Poor reviews indicate less than sterling health care. You don't want to have to fight for proper health care.
Company reputation can be very important if it accurately reflects reality. Keep in mind that what a few people think is anecdotal and not necessarily reflective of reality. Experience indicates that the more people with HIV you know who have a positive experience with an insurer, the more likely you are to be satisfied with the insurer.
If the insurer isn't here to pay your claims, you are not only responsible for future medical expenses,you are also responsible for expenses incurred while the insurer was solvent which weren't paid.
We rate pre-authorization to bring it to your attention. It has been a primary part of managed care that most people who have managed care plans have not been pleased with. It has been known to be used by some companies to deny people appropriate care. On the other hand, surveys by Consumer Reports indicate that people with chronic conditions with managed care policies are basically as satisfied with their health care coverage as people in fee-for-service plans.
External appeals have proved to be very helpful to people with HIV.
FEATURE
For each feature, read the description.
IMPORTANCE
Click on setting that reflects importance to you.

Enter Plan Name

Enter Plan Name

Enter Plan Name
RATE how well each plan meets your needs.
HEALTH CARE PROVIDERS
Choice of Doctor:

How easy/difficult is it to choose and/or change doctors? Can you continue to use your current doctor, if desired? Can your HIV doctor be your primary care physician? Are the doctors you care about accepting new patients? See: How To Choose A Doctor
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Excellent = Choice of any doctor. Your payment is the same. Doctors you may want to see are taking new patients.
Average = Choice from selected doctors. Can use certain specialists as primary care physician. LImited extra charge for doctors outside network.
Poor = Very limited choice. Doesn't include your doctor, so you have to change doctors. Extra charge to see doctors outside network. Can only change doctors once a year.
Quality of Doctors:

Are the doctors in your plan board-certified? Do they have experience with HIV? See How To Choose A Doctor
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Excellent = Plan requires board certification. Doctors have substantial experience with HIV. Poor = Few board-certified doctors. Few doctors with experience with HIV.
Choice of Hospital

Available hospitals: Can your doctor see you there? Are the hospitals experienced in treating HIV/AIDS? Is preauthorization required before entering a hosiptal? See How To Choose A Hospital

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Excellent =Choice of any hospital, no preauthorization. A lot of experience with HIV/AIDS.
Average = Limited to hospitals in network, some preauthorization required. Some HIV experience.
Poor = Restricted to unaccredited hospitals. Preauthorization required.
Access to Specialists

Can you see an HIV doctor or other specialist any time you want? If not, is it difficult to get referrals to a specialist? If necessary, are you permitted to see a specialist outside the plan?s network? 
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 Excellent = Unrestricted access. Average = Access to non-network specialists costs more. Poor = Access to in-network specialists only after obtaining a referral.
Second and Third Opinions:

 Is a second or third opinion from an HIV or other specialist covered? If so, can you use a specialist outside of your network?
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 Excellent = Unrestricted access. Average = Access to non-network specialists costs more. Poor = Access to in-network specialists only after obtaining a referral.
MONEY
Premiums:

Your share of the cost of purchasing health insurance. There may be discounts for healthy living.
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Varies with Plan and Geographical Area.
Annual Deductible:

How much you pay per year for covered charges before the insurance takes over payment.
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Excellent = None
Average = $500
Poor = $1000+ unless accompanied by a tax advantaged Personal Health Account, such as a Flexible Savings Account.

Coinsurance:

The percentage of charges you pay after the deductible is met. If there is no coinsurance, skip this question.
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Excellent = 10% Average = 20% Poor = 50%
Co-payments:

The dollar amount you pay per service. This usually applies to HMO Plans, or to the "in network" charges of a PPO or POS plan. If your plan only pays on a percentage of charges basis, skip this question.
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Excellent = $10 or less Average = $15 - $25. Poor = $50+
Annual Out-of-Pocket Maximum ("Cap"):

After you've paid this amount in deductibles, copayments, and coinsurance, the plan pays 100% of covered charges.
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Excellent = $1,000 or less. Poor = $5,000 or more
Are you involved in billing?

With managed care plans such as an HMO, your paperwork is minimal. With fee-for-service type plans, you pay the provider and get reimbursed. (See: Keeping Track of Medical Bills)
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Excellent: No paperwork. Average: Some paperwork. Poor: You do the paperwork.
Lifetime Maximum:

The most the insurer will pay over your lifetime. Some plans, particularly managed care type plans, have no limits.
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Excellent = Unlimited. Average = $2,000,000. Poor = $250,000
BENEFITS/POLICY TERMS
Complementary/Alternative Therapies

More and more plans cover complementary and/or alternative therapies
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Excellent= Full coverage like any Western medical treatments. Average= Limited coverage. Poor= No coverage.
Dental:

Policies may provide coverage for regular dental work, including preventive, or only dental work necessitated by a health condition or treatment.
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Excellent= Full coverage, including preventive. Small co-pay. Average= Some coverage. Poor= No coverage.
Prescription Drug Coverage:

Are all the drugs you use, or are likely to use, on the formulary (list of covered drugs)? What are co-pays for your drugs? Do you have to try other drugs before coverage for a prescribed drub? Are non-formulary drugs covered? What is the insurer position on off-label uses? See: Drugs 101.
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Excellent = Wide range of drugs covered, including those you need. Low co-pay for drugs you use. Off-label use permitted.
Average = All drugs you use are on formulary. Reasonable co-pay.Off-label use requires pre-authorization.
Poor = Very strict formulary with some or all of your drugs not covered. High co-pays for your drugs. Have to use other drugs before a prescribed expensive drug.

Drug/Alcohol Treatment:

Does the plan cover? Is treatment restricted, such as to network facilities, or number of days? If this doesn't apply to you, skip this question.
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Excellent = Detoxification plus rehabilitation covered. Average = Covered with time limits and preauthorization. Poor = Not covered.
Durable Medical Equipment and Supplies:

Medical items for use at home, ranging from items such as a hospital bed to mobility aids such as braces, crutches and wheelchairs.
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Excellent = Covered without limitation. Poor = No coverage
Experimental Drugs/ Treatments:

Some plans cover medical expense (such as exams or blood work) related to clinical trials of drugs or treatments that are not yet FDA approved.
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Excellent = Covered
Poor = Not Covered.
Home Health Care Services:

Some plans only cover skilled care -- care usually provided by nurses. Others may cover custodial care (help with basic daily activities such as toileting and bathing) and/or homemaker services (cooking and cleaning.)
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Excellent = Both skilled care and homemaker services. Poor = Skilled care only with a limited number of days? coverage.
Hospice Care:

Hospice care is end-of-life care when a patient seeks comfort instead of a cure. Are there restrictions, including where hospice care must be provided? (Note: all plans require that you be certified as having a life expectancy of less than six months.)
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Excellent = Choice of facility and where to have hospice care.
Average = Coverage with some restrictions
Poor = No coverage

Payment of Hospital Expenses:

Do you pay more to go to a non-network hospital? Are there limits on hospital expense and/or time in hospital?
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Excellent = All hospital charges covered, no separate deductible, unlimited number of days per year.
Average = You pay more for non-network or speciality hospitals.
Poor = Limited to a certain dollar amount per day in the hospital, limited number of days per year.

Mental Health Counseling (Outpatient):

Most plans have strict limits on how many visits they cover, how much is paid per visit, and what type of mental health counselor is covered (e.g. psychiatrists, psychologists, therapists.) Some plans rely heavily on medication as source of treatment. To learn more, see: Depression
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Excellent = 50 visits per year with no dollar-limit; any type of counselor.
Average = 20 visits per year, with 50% of fee covered, up to a dollar amount that varies by location. Psychiatrist or psychologist only. Treatment emphasis is medication.
Poor = No coverage.

Inpatient Treatment for Mental Health Counseling:

Many plans strictly limit in-hospital benefits.
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Excellent = Unlimited coverage. Average = 30 days. Poor = Not covered.
Organ Transplants:

Are organ transplants covered?
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Excellent = All transplants, including experimental transplants performed at a center that has transplant expertise. Average = Covered, but only up to a specific dollar amount. Poor = Not covered at all.
Patient Assistance:

 Does the company have a health coach, care manager, or nurse hotline to answer questions about HIV/AIDS and about your health care? A consumer advocate or consumer-advisory board to help you with problems? Case managers or disease management services to coordinate care for people with chronic or serious conditions?
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Excellent = Health coach or similar service. Extensive, fair, and quick review procedures and case management systems.
Poor = No consumer advocate and no case management services.
Pre-Existing Condition Exclusion:

If you're changing plans, is there a period of time during which there is no coverage for a pre-existing illness? (If so, check HIPAA and your state law to see if it's legal. Also see Uninsured. )
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Excellent = None. Poor = 12 Months
Preventive Treatments:

Items such as check-ups, flu shots, annual physicals, and mammograms are not covered by all plans.
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Excellent = Full range of preventive services covered. Poor = None covered.
Reconstructive Surgery:

Reconstructive surgery may or may not be covered under various plans.
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Excellent = Covered. Poor = Not covered at all.
Rehabilitation Therapy:

Designed to help patients recover from physical changes caused by a health condition or its treatment. Includes physical therapists, counselors, speech therapists, and other professional services.
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Excellent = Covered without limitation. Poor = No coverage.
Relationship to Medicare:

If you have Medicare, or might get it while you are still covered under the plan, check to see how benefits are paid.
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Excellent = Medicare supplements insurance payment. Poor = Medicare payment reduces insurance payment.
Renewals:

Individual plans may not always be guaranteed renewable. (If you have a group plan, skip this question.)
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Excellent = Guaranteed Renewable. Poor = Not guaranteed
Travel:

Are you covered for medical costs incurred when you are away from home? (See: Travel)
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Excellent = Covers regular charges anywhere in the world.
Average = Covers all charges anywhere in the United States, and emergency charges outside the United States
Poor = No coverage outside of home area.
QUALITY
Independent Organization Reviews:

Check online to see how each plan is rated by independent organizations such as http://hprc.ncqa.org , www.ahrq.gov, www.urac.org. Ask your State Insurance Department about complaints. (Find your department at www.naic.org)

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REFER TO ORGANIZATION RATINGS
Insurer Reputation/ Word of Mouth:

What is the experience of others you know who use this company with respect to issues you care about? Do doctors stay in network? Can you get through to a live person easily? Ask around. If you?re in a support group, ask members about their experience.

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RATE BASED ON HOW THE EXPERIENCES OF OTHERS ADDRESS YOUR NEEDS.
Insurer Financial Rating:

Check each insurer's financial rating online at www.ambest.com, www.standardandpoors.com or www.weissratings.com.
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Excellent = A or A+. Average = B+ or A-. Poor = B or below.

PROCEDURE
Pre-Authorization

Is pre-authorization required before undergoing tests and/or procedures?
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Excellent: No authorization required. Average: Authorization required for some tests or procedures. Poor: Always required, except for emergencies.
Appeals:

All plans have internal appeals. Does the appeal process permit outside review?
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Excellent: Allows outside review.
Average: Permits internal reviews only.
Poor: No appeal permitted.

Totals
Score: