October 21, 2016
According to findings from the Kaiser Family Foundation (KFF), Medicare and Medicaid have played a critical role in HIV care since the HIV epidemic began.
As the size of the American HIV population grows over time, due to an increased lifespan for people with HIV, the number of Medicare and Medicaid beneficiaries with HIV has also grown. Likewise, for both Medicare and Medicaid, spending has increased over time reflecting the growing numbers of beneficiaries with HIV. As of the report, Medicare is the single largest source of federal financing for HIV care and treatment.
Despite the growing number of beneficiaries in both Medicare and Medicaid, the HIV population makes up only a small portion. Medicare enrollees with HIV are less then 1% of the population, and there are approximately 242,000 Medicaid HIV positive beneficiaries, also less then 1%.
According to data, in 2016, Medicare spending on HIV patients totaled $10 billion, representing 51% of federal spending on HIV care, but just 2% of total Medicare spending. Among the 2016 Medicaid expenditures, HIV treatment makes up approximately $5.9 billion, representing 30% of all federal spending on HIV care. Medicaid is the second largest source of federal HIV care spending after Medicare.
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For HIV-positive beneficiaries under Medicare, the average per capita spending was reported at $45,489 in 2014—more than half of the spending ($26, 761) was for Part D drug expenditures. The annual spending on HIV-positive Medicaid beneficiaries was $26,807 in 2011, almost five times that of Medicaid beneficiaries overall ($5790).
HIV positive beneficiaries under both Medicare and Medicaid have a broad range of basic health care services. Medicare enrollees benefit from hospital care, physician services, and prescription drugs. Medicare is organized and paid for in four different ways including, Part A, hospital insurance; Part B, medical insurance; Part C, Medicare Advantage; and Part D, prescription drug benefit.
According to the KFF report, Medicare has high cost-sharing requirements, no cap on out-of-pocket spending under traditional Medicare for services covered under Parts A and B, and does not cover all services that may be important to people with HIV, such as long-term care and dental. If a patient requires additional cost-sharing assistance, Part D offers premium and cost-sharing for low income beneficiaries.
Similar to Medicare, Medicaid also offers a broad range of services. According to the report, “Traditional state Medicaid programs are required to cover “medically necessary” HIV testing and may elect to cover routine HIV testing. States are incentivized under the ACA to cover a full suite of preventive services, including routine HIV testing, without cost-sharing in exchange for a 1% increase in the federally matching rate for those services.”
Unlike Medicare, Medicaid enrollees who gain access through the Affordable Care Act (ACA) expansion receive an Alternative Benefit Plan which include services that fall into the ACA’s ten essential health benefits, many of which are important for HIV care. essential health benefits include:
- ambulatory patient services;
- emergency services;
- maternity and newborn care;
- prescription drugs;
- rehabilitative and habilitative services;
- laboratory services;
- preventive services and chronic disease management;
- pediatric services; and,
- mental health and substance use disorder services.
Furthermore, the ACA includes an option to provide Medicaid health home services to enrollees with chronic conditions, including HIV. Health homes encompass a range of services designed to help manage care for those who are chronically ill with HIV, such as comprehensive care management and care coordination.
For Medicare, the largest source of federal spending on HIV care, and Medicaid, the single largest source of health coverage for people with HIV, it will be important to continually monitor the status of each program as both will continue to play a growing role for people with HIV as the population ages and life expectancy increases. —Julie Mazurkiewicz