Private Insurance

The majority of women of childbearing age (70%) and children (66%) have their health care paid for through private insurance (Kaiser Commission on Medicaid and Uninsured, unpublished). Private insurance is usually obtained through employment directly or as a dependent of an employed person. Private health insurance on an individual basis is much more expensive, and the percentage of women and children with private insurance has declined steadily over the past decade (EBRI, 1997).

A number of issues about private insurance coverage for HIV/AIDS remain unresolved at this time. These issues include whether health plans can exclude from coverage individuals who have received a diagnosis of HIV infection before coverage; whether an employer can restructure a health plan to reduce benefits for a specific type of illness after a claim has been filed; and whether specific services will be considered "medically necessary" and therefore covered under insurance plans (Gostin and Webber, 1998). In June 1998, the Supreme Court, ruled in Bragdon v. Abbott, that individuals with asymptomatic HIV infection meet the legal definition of having a physical impairment under the Americans with Disabilities Act (ADA). The impact of this ruling on discrimination in insurance, as well as in employment and services offered by business and government, remains to be seen (Kaiser Family Foundation, 1998a).

The Health Insurance Portability and Accountability Act (HIPAA), passed in 1996, addressed private insurance coverage for people with pre-existing conditions, including those with HIV/AIDS. The law prohibits group health plans, insurers, and managed care organizations from denying coverage because of pre-existing conditions if the person had been insured for an uninterrupted 12 months prior to the application. In addition, the law:

  • limits to 12 months the time a person can be subject to a pre-existing medical condition exclusion if the individual had no previous health care coverage;
  • guarantees the availability of individual health insurance policies for those who leave jobs and have maintained previous coverage;
  • prohibits denial of coverage in group plans to persons in poor health; and
  • requires insurers to sell plans to small employers and guarantees renewal for both small group and individual coverage.

Although the HIPAA provides protections for those affected by HIV, it does not address the cost of premiums that insurers may impose, an important issue related to access.

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