Andrea Weddle, HIV Medicine Association (HIVMA), indicated that Medicaid reimbursement rates are a barrier to HIV clinic sustainability. According to recent estimates, Medicaid rates for primary care average 66 percent of Medicare rates and range from 47 percent (California) to 140 percent (Alaska) (Zuckerman et al., 2009).7 In general, the rates increased by 15.1 percent from 2003 to 2008; however, the consumer price index increased by 20.3 percent during this period. Weddle mentioned that states that have greater coverage of benefits tend to have lower provider payment rates. Low provider reimbursement rates have been shown to hinder access to care for Medicaid beneficiaries in particular (IOM, 2005).
Medicaid coverage of HIV testing is discussed in the committee’s first report (IOM, 2010). States must cover all medically indicated/physician ordered HIV tests, but states have the option to cover routine HIV screening.
Medicare Medicare is the federal health insurance program for individuals who are age 65 and older and individuals under age 65 who are disabled. Medicare provides coverage to 47 million Americans (KFF, 2010c), including an estimated 100,000 people with HIV/AIDS (KFF, 2009b). Medicare spending in FY 2010 is estimated at $515 billion with $5.1 billion in expenditures for HIV/AIDS (KFF, 2009e). The program has four parts:
1. Part A covers hospital stays, skilled nursing care, facility stays, home health care, and hospice care (automatically provided if eligible);
2. Part B covers physician payments, outpatient services, preventive services, and home health care (those eligible for Part A may enroll);
3. Part C covers Medicare Advantage (voluntary enrollment in private health plans, such as a health maintenance organization); and
4. Part D covers prescription drugs and low income subsidies (voluntary enrollment).
Most individuals with HIV who qualify for Medicare do so because they are disabled (see Table 5 for Medicare eligibility criteria). Medicare beneficiaries may choose to purchase coverage from a selection of competing private plans to cover prescription drugs under Medicare Part D. The cost sharing under Medicare Part D can be problematic for individuals with HIV who qualify on the basis of disability and are receiving Social Security Disability Insurance (SSDI) assistance. Cost-sharing may put pressure on AIDS Drug Assistance Programs (ADAPs), state-run programs funded
7 However, there have been recent reductions in provider reimbursement rates under Medicare.