(2) benefits, (3) provider reimbursement, and (4) possible cost saving measures. Two additional recommendations address integration and coordination of services within the program and with CARE Act funded services.
Recommendation 1: The federal government should establish and fully fund a new entitlement program for the treatment of low-income individuals with HIV that is administered at the state level.
To assist states in implementing the program, the federal government should pay for costs directly attributable to efficient administration of the program. To receive federal funding, states must ensure compliance with federal standards and operate programs according to principles of accountability and transparency. Under the federally sponsored program, the federal government would relieve the states of the full cost of providing care to HIV-infected individuals through their Medicaid programs.
The program has several primary design features that are critical to achieving the goals of the program. These features focus on eligibility requirements, benefits, access to experienced providers and provider reimbursement, quality and program management efficiencies, and interaction with other programs.
Most people receiving care for HIV/AIDS do so through Medicaid programs and the CARE Act program. In Medicaid, most states limit eligibility to those with HIV/AIDS who otherwise meet Medicaid disability standards. As a practical matter, this means that people only become eligible once they have advanced AIDS—resulting in disability and serious illness—and have low income. The benefits of HIV therapy are compromised by such delayed access. Therefore, people cannot get Medicaid coverage upon diagnosis with HIV, which would enable access to care that would prevent the costly onset of active disease and disability-related health costs. Eligibility for the CARE Act programs is usually based on HIV diagnosis. The program, however, varies by state and locality, as do the services available. Eligibility for ADAP within the program is generally offered to individuals with HIV infection with incomes typically under 300 percent of the federal poverty level (FPL) although a few states set eligibility at under 500 percent of FPL. Because ADAP operates under a defined appropriation with limited funding, many localities have waiting lists for eligible people to receive medication. Limiting eligibility to persons with AIDS disability and maintaining waiting lists for the commencement of drug therapies fundamentally contradicts the need for early and continuous access to care.