Q and A Categories
What is CAREAssist?
CAREAssist is the name for Oregon's AIDS Drug Assistance Program. These programs provide access to HIV medications for eligible clients, are available in all states and are funded by a combination of state and federal dollars. CAREAssist is part of the Oregon Health Authority HIV Care and Treatment program.
What is the income limit for CAREAssist?
Clients can make up to 500% of the Federal Poverty Level and still maintain CAREAssist. Before taxes, this is an income of $4,904 per month for a household of one.
What income should I report when applying or recertifying for the program?
Income is defined as any monies you and your household members consistently receive that are used to meet your basic needs. This includes, but is not limited to work income, unemployment benefits, SSI/SSDI, regular gifts from family/friends, self-employment income, payments from a trust or retirement account, etc.
Please note that failure to report income can result in termination from the CAREAssist program for up to a year. If you are unsure what may be considered income, please contact CAREAssist.
How does CAREAssist define "family"?
CAREAssist uses the federal definition of household to describe persons that live with you. "Household" means family or persons who are legally related to you. Here are some examples of how we calculate your family size (for purposes of definition, spouse refers to a person to whom you are legally married and partner refers to someone with whom there is not a legal marriage):
- You and your partner (not legally married), no children = household of 1
- You, your legal spouse, and 1 child under 18 = household of 3
- You, your child from a previous relationship, and your partner (not legally married) = household of 2
- If you and your partner (not legally married) have a biological child together = household of 3?
What do I do if I'm moving out of Oregon?
If you spend more than 3 consecutive months outside of Oregon (with the exception of fully enrolled students), you are not eligible for CAREAssist (Oregon's AIDS Drug Assistance Program or ADAP). If you move permanently to another state outside of Oregon, you may be eligible for ADAP services in another state. All states in the U.S. have ADAP, although ADAP programs vary from state to state.
What if I am an Oregon resident but I want to attend school out of state?
Students who attend an out-of-state school are eligible for CAREAssist as long as they maintain their residency in Oregon. Documentation of current enrollment in an educational institution is required. For purposes of income eligibility, student loans are not considered income.
What if I go to jail or prison?
If you go to prison or jail for more than 90 days, your CAREAssist membership will be terminated and you will have to reapply upon release. If you go to jail for less than 90 days, CAREAssist will likely maintain your benefits and may be able to assist with ensuring you are able to access medications while in jail.
How can I get more involved with CAREAssist?
There are a number of ways you can become involved in CAREAssist and make your voice heard.
As a member of CAREAssist, we welcome you to take part in the CAREAssist Advisory Committee. The purpose of the group is to provide input and direction to the program related to CAREAssist client eligibility, program design and implementation. Meetings are held quarterly and are open to the public. Get more information about the Advisory Committee on our website, or ask your CAREAssist caseworker.
CAREAssist also conducts regular surveys to see how we're doing and to help us understand where we could improve our services. We welcome your responses, so please fill out and return any surveys that are mailed to you.
What is the deadline for submitting a bill to CAREAssist to cover?
Bills must be submitted within 12 months from the date of service, and you must have been a CAREAssist member at the time the service occurred.
Are some bills too big or too small for CAREAssist to cover?
CAREAssist will pay your part of the cost no matter how small or large the amount is, up to the annual maximum benefit for your group. See your Summary of CAREAssist Benefits for information on your maximum benefit.
How does CAREAssist get billed for my pharmacy copay?
First, you will need to talk with your CAREAssist caseworker to set up the pharmacy where you want to pick up your prescriptions. Once this is completed, you will need to inform the pharmacy that it will need to bill CAREAssist for your medication copay and you will need to present your CAREAssist card to them.
If you have any problems with this or if the pharmacy has questions, please contact your CAREAssist caseworker.
What if I paid for my copay myself? Will CAREAssist pay me back?
CAREAssist is unable to make payments directly to a client. In the event that you have paid a copay, deductible or premium out of your own pocket, you will not be reimbursed. To avoid this, make sure you provide your CAREAssist card to your doctor or pharmacist every time you receive a service or pick up a prescription.
Start saving the reports your insurance company sends you after each time your insurance is billed. These reports are called "Explanation of Benefits" or EOBs. Keep all your EOBs in one place and save them for at least 6 months. It's a good idea to do this whether or not you ever have to send CAREAssist a bill.
Can the doctor or lab bill CAREAssist directly?
Yes. Show your doctor's office your CAREAssist card and tell them that CAREAssist is acting as a "secondary payer."
The address for mailing claims to CAREAssist is on the back of your member card. It is best to check occasionally with the billing staff to make sure that they still have CAREAssist listed as your "secondary payer."
What if the doctor or lab bill is sent to me?
If you get a bill from the lab or doctor after your insurance has paid, it usually means CAREAssist did not pay that bill. If you want CAREAssist to pay, quickly send the bill and the Explanation of Benefits (EOB) that matches both the date and the amount owed. The address to mail CAREAssist your claims is on the back of your CAREAssist card.
If we do not get both the provider bill and the matching EOB, it will be sent back to you. We do not have the ability to track partial paperwork.
Can CAREAssist help a member with medical visit copays and deductibles?
Yes. CAREAssist will pay for doctor's office visits, lab tests, and any other insurance-covered services. A deductible usually happens at the beginning of the year and then copays follow that. Group 1 members can get up to $5,000 of assistance per year. Group 3 members can get up to $2,500 per year.
Can I access medications while on vacation?
Maybe. In most cases, you can obtain a vacation supply of medications PRIOR to leaving on vacation. This must be authorized by your insurance provider. CAREAssist will not make copayments to any out-of-state pharmacy without prior agreement, so make sure you have enough medication before going out of town.
If you're going out of town for more than a month, and have concerns about returning your Client Eligibility Review (CER), please call your CAREAssist caseworker.
Do clients have to use mail-order?
Most clients who are uncomfortable using a mail order pharmacy will not be required to do so.
Will CAREAssist pay for any medical service my insurance covers?
Yes. CAREAssist will pay your part of the cost as long as the service is approved by your insurance and the date of service is within the last 12 months. Sometimes there is a deductible amount that has to be paid before the insurance starts to pay. CAREAssist will pay that deductible if it is for a covered service. Typically, insurance pays 60% to 80% of the cost and then the doctor or lab service asks you for the rest. CAREAssist will pay your part, up to the maximum yearly amount noted above. Payments are made on all services, not just HIV-related care.