TABLE 4 Medicaid Eligibility Pathways for People Living with HIV/AIDS


Category Criteria Mandatory/Optional

SSI beneficiaries Severely disabled and low income (standard 74% of FPL, varies by state) Mandatory (11 “209B” states can have more restrictive eligibility)
Parents, children, pregnant women Low income; income and asset criteria vary by category and state Mandatory; states may offer higher income thresholds
Medically needy Severely disabled and low income, after subtracting incurred medical expenses; income and asset criteria vary by state but generally well below SSI levels Optional (33 states and the District of Columbia use this option for people with disabilities)
Workers with disabilities Severely disabled; low income; for persons returning to workforce Optional
Poverty-level expansion Allows for income above SSI levels up to FPL Optional
State supplementary payment Allows for coverage of those receiving SSP Optional

SOURCE: KFF, 2009a.

under Medicaid) (KFF, 2009b), and 19 states have prescription drug limits (e.g., monthly or annual limits on the number of prescriptions) within their Medicaid programs (KFF, 2008).

Heather Hauck, Maryland Department of Health and Mental Hygiene, discussed how some but not all states have Medicaid expansion programs allowing coverage for non-disabled individuals. In addition, there is limited coverage for nonmedical services, such as case management and housing, under Medicaid. Medicaid data system limitations may restrict the ability of administrators to assess who is in care and the appropriateness and outcomes associated with that care.

Other barriers to access to Medicaid coverage include the onerous application process in some states; a restrictive definition of disability that excludes persons with HIV who do not have an AIDS diagnosis and who are capable of engaging in “substantial gainful activity” (although this will be alleviated with changes to categorical eligibility criteria that will no longer require an AIDS diagnosis/disability under the ACA); and limited beneficiary autonomy in choosing a care provider (Rawlings and Hopson, 2009).



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