Public Insurance

Medicaid covers 32% of low-income women of childbearing age and 49% of low-income children under 18 (Kaiser Commission on Medicaid and Uninsured, 1998b). Medicaid is the second largest public financing mechanism for health care and the largest single payer of direct medical services for people with AIDS. Over 61.5% of women in care for HIV are insured by Medicaid (Rand, 1998). Medicaid also pays for the care of about 90% of children with AIDS (DHHS, 1998). In 1996 only 15% of women in care for HIV with an asymptomatic HIV diagnosis (CD4 count of 500 or above) had private insurance, 60% had public insurance (Medicaid and Medicare), and 25% had no insurance. As the disease progresses to AIDS (CD4 counts below 200), those with public insurance increased to 70% (Rand, 1998).

Under Medicaid, all states are required to cover maternity services through 60 days postpartum for pregnant women with incomes below 133% of the Federal Poverty Level (FPL) and, at state option, the income cut-off for pregnant women can be raised to 185% FPL (and the federal match still maintained). States are also required to cover infants born to Medicaid-eligible pregnant women through the first year of life. In addition, states must cover children through age 5 who live in families below 133% FPL, and children ages 6 to 13 whose family income falls below 100% FPL. Older children with family income below 100% FPL are to be gradually phased in until 18 year olds are covered in 2002. States have the option of expanding coverage for children beyond the minimum requirement, and as of October 1997, a total of 27 had chosen this option (Weil, 1997; Fine, 1997). Under the new, federal-state Child Health Insurance Program (CHIP), federal funds are available to states that choose to expand Medicaid coverage to children whose family incomes are up to 200% of poverty. Under CHIP, states may choose to expand Medicaid eligibility, or they may use the new federal funds to develop their own coverage programs for children.

The full range of services identified in a state Medicaid plan must be provided to all recipients, including those with HIV disease. In addition, some states offer optional services such as targeted case management, preventive health services, and hospice care. Not all physicians accept Medicaid as payment, however, because rates may be low, payment slow, and paperwork cumbersome. All public and private, nonprofit sites accept Medicaid payments, with the difference between the Medicaid reimbursement and the actual costs of the services provided at these sites often covered by grants, usually from the federal government to a community-based organization or to a state agency.

Medicaid currently covers all Food and Drug Administration (FDA) approved prescribed drugs, including those used for prophylactic treatment of AIDS-related opportunistic infections, and drugs for treatment of HIV disease and prevention of perinatal transmission. Although states are required to cover those



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