AIDS using Section 1915(c) waivers. HCBS waiver programs are for individuals determined to be at risk for institutional care and have been used for people with AIDS to maximize their independence through the use of services such as case management, adult day health care, and hospice care.60
States may place limits on some Medicaid services, and several limit the number of prescriptions allowed per month, the length of hospital inpatient services, and the number of physician visits (these limits cannot, however, be applied selectively to one group of beneficiaries). In 2003, for example, 14 states limited the number of prescriptions per month or year.61 States may also impose “nominal” cost-sharing requirements on most nonemergency mandatory or optional services with respect to adults (other than pregnant women and institutionalized patients). Emergency care, hospice care, and family planning services are excluded from cost-sharing.
Certain aspects of the Medicaid program present challenges to people living with HIV/AIDS, as well as to low-income adults more generally (since low-income adults mainly qualify for Medicaid after they are disabled). These include the following:
One main challenge facing low-income people with HIV/AIDS is a Medicaid eligibility “Catch-22”—many are not eligible for Medicaid until they become disabled, despite the availability of therapies that may prevent disability. Several options are being considered to address this, including:
Section 1115 Waivers. Several states have applied for or are considering Medicaid Section 1115 waivers to expand Medicaid eligibility to low-income people with HIV prior to disability.62 To date, three states—Maine, Massachusetts, and the District of Columbia—have received federal approval to operate such waivers. Only the Massachusetts and District of Columbia waiver is currently operational. A major barrier to the 1115 waiver strategy is that 1115 waivers must be “budget neutral” (i.e., the costs of the expansion over a designated period of time, usually 5 years, cannot exceed the costs to Medicaid in the absence of the expansion). This standard has been hard for states to meet. While analyses have shown that additional, non-Medicaid savings will accrue through such expansions (e.g., to SSI, SSDI, Medicare, and the Ryan White AIDS Drug Assistance Program), these savings cannot be included in budget neutrality calculations under current policy.17,30
The Ticket to Work/Work Incentives Improvement Act of 1999.