with pre-existing conditions. In the interim, adults with pre-existing conditions who have been without health coverage for at least 6 months are eligible to purchase coverage through federal or state-run, high-risk PCIPs (Figure 2-2; KFF, 2011a). In addition, insurance providers no longer can rescind coverage due to health status, except in cases of fraud or intentional misrepresentation (Keith et al., 2012; KFF, 2011a). The ACA also prohibits the imposition of lifetime dollar limits on coverage for essential health benefits and restricts and phases out annual dollar limits on coverage for essential health benefits, unless waived by the Department of Health and Human Services (HHS).9 Waivers for annual dollar limits on coverage will be discontinued in 2014, eliminating annual dollar limits on coverage for all plans in small- and large-group markets (Keith et al., 2012).
Medicaid currently is the largest single source of health care coverage for people living with HIV, providing coverage for 47 percent of HIV-infected individuals estimated to be receiving regular medical care (Kates, 2011, p. 1). In fiscal year 2007, 212,892 Medicaid beneficiaries were HIV-positive (Kates, 2011, p. 1). In states that choose to expand their Medicaid program as allowed under the ACA, Medicaid eligibility will be extended to most “non-Medicare eligible individuals under age 65 (children, pregnant women, parents, and adults without dependent children)” with incomes up to 133 percent of the FPL (Figure 2-3; KFF, 2011a).10 Currently, most Medicaid beneficiaries with HIV (74 percent) qualify through the disability pathway, meaning their disease is sufficiently advanced to preclude them from working (Kates, 2011, p. 4). With Medicaid expansion, as passed by law under the ACA, low-income individuals who have HIV, including those without dependent children (“childless adults”), will be eligible for Medicaid before their disease becomes disabling. For those who become newly eligible for Medicaid, the federal government will assume 100 percent of Medicaid costs during 2014-2016, phased down to a minimum of 90 percent thereafter.
Where Medicaid is expanded, particularly if coupled with more effective enrollment of currently eligible individuals, it is expected that there could be as many as 11.6 million new people entered into the Medicaid system in 2014 and 20 million by 2019, representing 21 and 34 percent increases, respectively, over pre-ACA projections (CMS, 2010). It is anticipated that the majority of individuals with HIV who currently receive clinical or related
9A discussion of “essential health benefits” is included later in the chapter.
10Recent (less than 5 years in the United States) and undocumented immigrants will remain ineligible for Medicaid.