advanced to AIDS is fundamentally at odds with the demonstrated value of early and continuous access to HAART therapy. The Committee therefore recommends that categorical eligibility for coverage be based upon a medical determination of HIV infection.

With respect to income eligibility, there is no commonly agreed-upon standard for “low-income.” Different means-tested programs apply different tests. For example, the minimum Medicaid income eligibility standard for an individual with disabilities who qualifies on the basis of receiving Supplemental Security Income (SSI) cash assistance is 74 percent of the federal poverty level. State Medicaid programs have discretion to set higher income standards for individuals with disabilities, and many of them have, resulting in considerable variation from state to state. The Ryan White CARE Act program uses less restrictive standards. Reflecting the high costs of HAART, eligibility for the AIDS Drug Assistance Program (ADAP) is offered to individuals with HIV infection with incomes at least under 500 percent of the federal poverty level in two states (Delaware and New Jersey). The majority of ADAP clients (92 percent) have incomes below 300 percent of the federal poverty level. However, the ADAP income standard applies to coverage for prescription drugs only, not for the full range of medical and related services needed to manage HIV/AIDS.

Because of the high cost of HAART and the comprehensive care necessary for effective treatment of HIV/AIDS, the Committee concludes that the income eligibility standard for the new federal program should be 250 percent of the federal poverty level ($22,500 for an individual in 2003). This standard is higher than the minimum Medicaid eligibility standard for disabled SSI recipients but is consistent with the standard applicable to working disabled individuals eligible for Medicaid at state option under the Balanced Budget Act of 1997 (1902(a)(10)(A)(ii)(XIII) of the Social Security Act added by section 4733(3) of the Balanced Budget Act, P.L. 105-33). This is lower, however, than the standard commonly applied in the ADAP program. Unlike the new federal program recommended by the Committee, ADAP does not cover services other than prescription drugs and does not guarantee coverage of the prescription drugs it offers to each individual with HIV who qualifies under its income standard.

Notwithstanding the differences between ADAP and the new federal program, the Committee recognizes that the adoption of an income standard lower than that now in use under ADAP will potentially pose a hardship to many individuals now receiving ADAP assistance. The Committee therefore recommends that, in determining whether an individual meets the 250 percent income standard, a “spend-down” methodology be applied similar to that used by many state Medicaid programs in determining income eligibility for individuals with disabilities through the “medically needy” eligibility category. Under this methodology, an individual’s incurred

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement