Protecting HIV Care in Florida's Marketplace

Why This Guide Exists

For many people living with HIV in Florida, health insurance is not abstract policy. It is medication refills, lab monitoring, and appointments that keep viral loads suppressed and long-term health stable. Staying in regular HIV care and taking treatment as prescribed is what allows most people living with HIV to reach and maintain an undetectable viral load — even short coverage gaps can interrupt that continuity.^[1]

If a Marketplace transition becomes necessary, this resource provides a clear framework to evaluate your options without risking continuity. It is designed for individuals navigating this on their own, case managers supporting clients, and clinics helping people make informed enrollment decisions.

Florida Marketplace Realities to Understand First

Florida uses the federal Marketplace at healthcare.gov. Plan availability, pricing, and provider networks vary by county. Nationally, the large majority of Marketplace enrollees are in HMO or EPO plans, and Florida follows that same pattern — true PPO options with out-of-network coverage are limited.^[2]

Before enrolling in any plan, confirm:

• Your HIV provider is in network
• Specialists and hospitals you use are in network
• Your HIV medication is on the formulary
• The medication's tier placement and cost-sharing structure
• Whether a specialty pharmacy is required for your medication

If you rely on mental health or substance use services, confirm those providers are in network. If you are aging with HIV, review how the plan handles ongoing specialist care — cardiology, endocrinology, oncology, or other chronic condition management.

Understanding Tiers and Cost Sharing

When you enroll in a Marketplace plan, your medication is placed on a formulary tier. That tier determines how much you pay out of pocket at the pharmacy.

Lower formulary tiers typically include generics with flat copays. Higher tiers — where most HIV medications land — often involve coinsurance. Even 20–25% coinsurance on a medication with a negotiated cost of several thousand dollars per month can mean hundreds of dollars out of pocket per refill, until your deductible or maximum is reached.

A plan with a lower monthly premium might have a higher medication coinsurance that costs far more over the course of a year. A plan with a higher premium and a flat $100 copay could end up being significantly less expensive if you refill every month. Do the math before you decide.

A simple question to ask yourself: If I had to refill my medication tomorrow, would this plan feel financially stable? Prioritize the plan that protects uninterrupted access to your medication. Sustainability all year matters more than a lower number on the enrollment screen.

Understanding Metal Levels

Metal levels describe cost sharing structure — not the quality of care you receive. All plans cover the same Essential Health Benefits.

Deductibles and out-of-pocket maximums reset January 1 each year. If you switch plans at any point during the year, everything resets — payments made toward your prior plan's deductible do not carry forward.

Income, Tax Credits & What Changed in 2026

To qualify for premium tax credits in 2026, your projected annual income must fall between 100% and 400% of the Federal Poverty Level, based on 2025 federal poverty guidelines. For a single-person household, that range is approximately $15,650 to $62,600.^[5]

If your income falls below $15,650 (100% FPL), you may fall into Florida's coverage gap. Because Florida is one of the states that has not expanded Medicaid, adults below that threshold generally do not qualify for either Marketplace subsidies or Medicaid — Florida accounts for one of the largest shares of people caught in this gap nationwide.^[7] If this applies to you, speak with your HIV case manager or clinic. The Ryan White HIV/AIDS Program, including Florida's AIDS Drug Assistance Program (ADAP), exists specifically to help bridge medication and coverage gaps for people who don't qualify for other assistance.^[8] Our Florida Care Resource Guide can connect you to local support.

Premium tax credits are based on your projected annual income. If your actual income ends up higher than expected, you may owe money back when you file your federal taxes. Previously, taxpayers under 400% FPL were protected by caps that limited how much they had to repay. Those caps were eliminated for tax years beginning after December 31, 2025, so any excess advance credit must now be repaid in full.^[9] Report any income changes to the Marketplace during the year — do not wait until tax season to find out you owe more than you can manage.

Key ACA Protections to Know

• Marketplace plans cannot deny coverage, cancel coverage, or charge you higher premiums because of HIV or any other pre-existing condition^[10]
• All Marketplace plans must cover the same 10 categories of Essential Health Benefits, including prescription drugs, laboratory services, hospitalization, preventive care, and mental health^[11]
• The difference between plans is not whether HIV care is covered — it is how it is covered and what cost sharing applies to your specific medications and providers
• If your medication is not covered or placed on an unfavorable tier, you have the right to request a formulary exception or file an appeal^[12]
• If you do not make changes during Open Enrollment, you may be automatically re-enrolled into the same or a similar plan — review your plan every year before accepting auto-renewal^[13]
• Keep your address and contact information updated with the Marketplace to avoid missing important notices or facing unintended termination

If You Are Comparing Plans Yourself

When reviewing plans on healthcare.gov, go beyond the premium. Before deciding, look at:

• Deductible — and whether there is a separate prescription deductible
• Annual out-of-pocket maximum
• Your HIV medication's tier placement and coinsurance or copay structure
• Whether your HIV provider, specialists, and labs are in network
• Specialty pharmacy requirements for your medication
• Copays for office visits, urgent care, ER, and hospitalization
• Coverage effective date

Save all documentation — your application confirmation, plan summary, premium amount, and medication cost information. If you have a case manager, bring this to them before finalizing. A second set of eyes on a plan decision can prevent a costly mistake.

If Someone Else Is Enrolling You

Enrollment should never feel rushed or unclear. Before finalizing coverage, confirm these details and ask for copies of everything:

For Case Managers and Community Partners

A few reminders before finalizing coverage for a client:

• Confirm income eligibility and the 100–400% FPL range before selecting a plan — the enhanced subsidy rules no longer apply in 2026
• Verify plan effective dates and enrollment confirmation before the client leaves
• Document clearly who is responsible for premium payments and what happens if assistance changes or ends
• Educate clients that the repayment caps protecting low-income individuals have been eliminated — income reporting during the year is more important than ever^[9]
• Remind clients that deductibles and out-of-pocket maximums reset January 1 — switching plans mid-year means starting from zero

Ryan White HIV/AIDS Program funding and other assistance programs may help with medication costs, premiums, or cost sharing depending on eligibility and local program rules — Ryan White is designed to be the payer of last resort, filling gaps other coverage doesn't reach.^[8] Connect clients to your local Ryan White program or ADAP coordinator for coordination of benefits.

References & Sources

1. HIV.gov. HIV Care Continuum. hiv.gov ↩
2. KFF. How Narrow or Broad Are ACA Marketplace Physician Networks? kff.org ↩
3. HealthCare.gov. Contact Us — Marketplace Call Center. healthcare.gov ↩
4. HealthCare.gov. Cost-Sharing Reductions. healthcare.gov ↩
5. HealthCare.gov. Federal Poverty Level (FPL). 2025 guidelines used for 2026 coverage-year eligibility. healthcare.gov; KFF, How Much Can I Earn and Qualify for Premium Tax Credits in the Marketplace? kff.org ↩
6. IRS. Questions and Answers on the Premium Tax Credit. Income eligibility reverts to 100–400% FPL for tax years after 2025. irs.gov ↩
7. KFF. How Many Uninsured Are in the Coverage Gap, and How Many Could Be Eligible If All States Adopted the Medicaid Expansion? Florida accounts for roughly 19% of the national coverage gap. kff.org ↩
8. HRSA Ryan White HIV/AIDS Program. Part B: AIDS Drug Assistance Program (ADAP). ryanwhite.hrsa.gov ↩
9. IRS. Questions and Answers on the Premium Tax Credit. No repayment cap applies for tax years after 2025. irs.gov ↩
10. HealthCare.gov. Pre-Existing Conditions. healthcare.gov ↩
11. HealthCare.gov. What Marketplace Health Insurance Plans Cover. healthcare.gov ↩
12. KFF. How Can I Find Out If a Health Plan Covers the Prescription Drugs That I Take? kff.org ↩
13. HealthCare.gov. Automatically Re-Enrolled in a Marketplace Plan. healthcare.gov ↩