A Letter to the Tenn. Dept. of Commerce and Insurance


I have been living with HIV since 2007.  Throughout my life since my diagnosis, I have been in and out of steady employment, as my diagnosis coincided with the downturn of the economy.   Even when I had steady employment, I still found it difficult to be able to afford the copays, deductibles, medicines and labwork required with modern HIV treatment.  

When a person begins on HIV medication, they must remain on that medication for the duration of their lives.  We can NOT go on and off medicine.  We can NOT miss even a single dose of medication as the HIV virus would mutate quickly and the medicine would no longer be effective.  

Too often, the systems in place for care fail those of us with HIV.  Applying and remaining on state and federally assisted Ryan White programs or ADAP require a great deal of paperwork, time, and hassle.  I have never had a quick and easy experience applying for Ryan White assistance.  I am happy to know that health care will now be federalized starting in 2014 and that is why I am writing to you.

On behalf of more than 19,000 Tennesseans who are living with HIV and AIDS and countless others that are affected, I urge you to ensure that the Essential Health Benefits (EHB) benchmark for the health insurance exchange established under the Patient Protection and Affordable Care Act guarantees adequate coverage for people living with HIV and AIDS and other vulnerable populations.

This should include the following services:
·         A prescription drug formulary that supports the current standard of care for people living with HIV is critical. This standard prescribes a minimum of three antiretroviral drugs to effectively suppress the virus. Thus, plans that cover only one or even a few drugs in each category or class covered by the benchmark would not support the current standard of HIV care. Explicit provisions, such as those provided by for the six “protected” classes on the Medicare Part D drug program, are necessary. The formulary should also include medications to treat side effects and other co-occurring conditions like viral hepatitis. 
·         Access to HIV experts, including those trained in infectious diseases, without excessive restrictions, for instance through repeated preauthorization or high co-payments for specialty care.  
  • Access to the range of services effective for treating mental illness and substance abuse disorders  to prevent inpatient hospitalizations  and to support people living with HIV and AIDS in adhering successfully to prescribed care and treatment.
  • Coverage of laboratory tests every three to six months to assess an individual’s response to HIV therapies as well as the development of co-occurring conditions as a result of treatment or disease progression.
  • Case management, which helps those living with HIV and AIDS access services to stay healthy and reduce the use of more intensive and more costly health care services, should be included and defined to include care and services system coordination and navigation, along with HIV/AIDS treatment and care adherence counseling, education and support, both in and outside medical settings.
  • Preventative services, including sexually transmitted infections screening and counseling, FDA-approved contraception and contraceptive counseling, and domestic violence screening and counseling, as well as annual HIV screening and counseling. 

The EHB benchmark should prohibit insurance companies from limiting access to medically necessary health care services through dollar or visit limits on essential services, condition-specific restrictions, excessive cost-sharing, and/or unduly burdensome utilization management and prior authorization requirements.

I sincerely appreciate the opportunity to comment on the Essential Health Benefits Plans under consideration by the department and look forward to working towards a benchmark that meets the needs of people with HIV/AIDS and other vulnerable populations in Tennessee.

Sincerely,

Jason McDonald
Knoxville, TN
jjemcdonald@yahoo.com
Phone: 865-xxx-xxxx

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