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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White
allows states to use CARE Act funds to help people with HIV/AIDS who are eligible for Consolidated Omnibus Budget Reconciliation Act (COBRA)5 health benefit provisions to pay their premiums or buy private insurance. Title II AIDS Drug Assistance Programs (ADAP) may also purchase health insurance services for clients that include a full range of HIV treatment and primary care services. HIP also allows funds to be used to pay family health insurance premiums to ensure insurance continuation for a family member and to pay for public or private copayments and deductibles for persons with HIV disease.
Certain elements of the Medicaid program create access problems for people living with HIV/AIDS, most notably, the eligibility criteria (Boxes 4-1–4-5). Most adults, for example, are denied entry into the program until they become disabled, long after the standard of care would call for intervention and despite the availability of therapies that may prevent disability (Kates, 2004; Levi and Kates, 2000). To tackle this problem, some states have applied for a Medicaid research and demonstration waiver to expand Medicaid eligibility to low-income people with HIV prior to disability.6 However, waivers must be budget neutral, meaning that programs conducted under a demonstration should not cost the federal government more than would have been spent under the program absent the demonstration. This criterion has been difficult for many states to meet (Kahn et al., 2001; Schackman et al., 2001). Also, federal consideration and approval of waivers may take years. For example, an HIV waiver submitted by the state of Georgia in 2000 had not been approved as of November 2003.
Medicaid beneficiaries often lose eligibility for Medicaid if they return to work. Access to life-saving antiretroviral therapy through the Medicaid program allows many HIV beneficiaries to feel well enough to return to work, but health improvement may be a double-edged sword. The return to work and income earned can place individuals at income levels above the Medicaid eligibility level for participation in the program. The Balanced Budget Act of 1997 gave states the option to allow low-income individuals to keep their Medicaid coverage while working and earning income up to 250 percent of poverty level. The Ticket to Work/Work Incentives Improvement Act (TWWIIA) of 1999 provides a similar option. TWWIIA expands
Enacted in 1986, COBRA amends the Employee Retirement Income Security Act, the Internal Revenue Code, and the Public Health Service Act to provide continuation of group health coverage that otherwise might be terminated.
Section 1115 waivers allow states to experiment with how their Medicaid programs cover and deliver services.