eligibles will be identified for this purpose. This could mean that some dual eligibles might experience a lapse in prescription drug coverage if they have not yet enrolled in Part D, a situation that could be particularly problematic for people with HIV/AIDS on HAART regimens for which adherence is critical and for those fighting opportunistic infections.

• Difficulties navigating the enrollment process. It is also likely that the enrollment process for Part D will present challenges, particularly for low-income populations and this too could delay enrollment.

• Out of pocket costs. Co-payments may also pose barriers for some beneficiaries, particularly low-income beneficiaries, despite the law’s provision for a low-income subsidy program. In some cases, co-payments may be higher under the new law than what dual beneficiaries were required to pay under Medicaid. In addition, beneficiaries will have to pay 100% of the costs of any drug not covered by their plan.

• Denial of prescription drugs if co-payment cannot be met. Under the new law, beneficiaries can be denied a prescription if they cannot meet the co-payment. This kind of restriction is barred under current Medicaid law.

Ultimately, how the new law will play out and what effect it will have on people with HIV/AIDS and the other programs that serve them (e.g., will it lead to increased demand for ADAP? increased costs? reduced access to prescription drugs?) remains unclear.

First enacted in 1990 and reauthorized in both 1996 and 2000, the Ryan White CARE Act provides funding to cities, states, and other public and private nonprofit entities to develop, coordinate, and operate systems for the delivery of health and support services to medically underserved individuals and families affected by HIV disease. The Ryan White CARE Act is administered by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. The CARE Act functions as the payer of last resort—that is, providing care to individuals who are uninsured or underinsured and cannot cover the costs of care on their own, and because no other source of payment for services, public or private, is available to them.⁸⁰

The CARE Act was first designed to fill the gaps in financing care for people with HIV/AIDS and to relieve cities that were bearing a disproportionate burden of the cost of care. It has since grown into a major program that has helped create an AIDS care infrastructure across the country. In FY 2003, federal funding for Ryan White was approximately $2 billion, about three times its funding level in FY 1995 ($657 million), largely