Federal and State Health Insurance Programs4

Medicaid Medicaid is the nation’s principal safety-net health insurance program and represents the largest expenditure on health coverage for people with HIV/AIDS when federal and state expenditures are combined. The program is a federal-state partnership, with each state and territory operating its own Medicaid program under broad, federal guidelines. Medicaid is a guaranteed entitlement to U.S. residents and documented immigrants, and federal funding is provided to match state funds for those eligible for coverage. In 2009, 47.8 million people were covered by Medicaid (DeNavas-Walt et al., 2010). An estimated 200,000–240,000 individuals with HIV/AIDS receive care through the Medicaid program (KFF, 2009a). Federal spending on Medicaid in FY 2010 is estimated at $275.4 billion,5 with an estimated $4.7 billion going to HIV care (KFF, 2009b), and additional state spending on HIV care is estimated at close to $4 billion (CMS, personal communication, September 2010).

Minimum eligibility requirements for Medicaid are set by federal law. To be eligible for Medicaid, an individual must be both low income and “categorically” eligible. There are several pathways to Medicaid coverage (Table 4). The large majority of persons with HIV on Medicaid qualify on the basis of being both low income and disabled, as determined by their eligibility for Supplemental Security Income (SSI) benefits. Because states have discretion in designing and administering Medicaid programs, there is considerable variation by state in eligibility, benefits, and other aspects of program. In addition to the mandatory groups that all states must cover to receive federal matching funds, there are optional eligibility groups that states can choose to cover and receive federal matching funds. For instance states have the option to offer eligibility for individuals with income above the threshold for the state (Table 4) (KFF, 2009a).

Income eligibility requirements for Medicaid vary greatly by state, and are often very restrictive. For instance, in 34 states, low-income parents must have incomes less than the federal poverty level (FPL) to be Medicaid eligible; in 17 states, incomes must be less than 50 percent of the FPL (KFF, 2009c).6 Programs and benefits also vary. For example, only 33 states and the District of Columbia have a program for individuals who are medically needy to serve people who have incomes that are too high to qualify for Medicaid but who are otherwise eligible (this is an optional program


4 This section is based primarily on the presentations of Jennifer Kates, Deborah Parham Hopson, Heather Hauck, and Andrea Weddle.

5 See http://origin.www.gpo.gov/fdsys/pkg/BUDGET-2011-TAB/xls/BUDGET-2011-TAB-16-1.xls.

6 The FPL is an income threshold that is used as a measure to determine eligibility for assistance through several federal programs.

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