Medicare is the federal health insurance program for seniors and people under age 65 with permanent disabilities. It accounts for approximately one quarter of federal spending on HIV/AIDS care in the U.S. and is also an important source of coverage for people living with HIV/AIDS.
The Medicare program is run by the Centers for Medicare and Medicaid Services (CMS), under the Department of Health and Human Services (HHS).
Medicare was originally established in 1965 with the passage of the Social Security Act. It was a monumental change for the half of older Americans who had previously had no access to health insurance. In the nearly fifty years since then, Medicare has undergone a lot of change including the expansion of benefits, different payment options, and expansion of coverage to include people with permanent disability. As the program and the population it serves have grown, so have the costs of maintaining Medicare. The costs are split between the State and Federal government.
The Medicare and Medicaid programs represent the largest sources of care for people living with HIV/AIDS in the United States. It covers approximately one fifth of people with HIV estimated to be receiving care in the United States, however, these individuals represent only a small fraction (around .01%) of the overall Medicare population. Most people with HIV on Medicare are under age 65 and qualify as disabled beneficiaries.
Most people with HIV who qualify for Medicare do so because they are determined to be disabled and receive Social Security Disability Insurance. Only a small share are eligible as seniors.
With the implementation of the Medicare Part D prescription drug benefit in 2006, Medicare assumed an even more critical role for people with HIV, as it began to pay for prescription drugs. Part D covers all approved anti-retroviral medications, as one of six protected classes of drugs.
The HHS FY 2010 HIV/AIDS funding estimates, including discretionary and entitlement funding, total approximately $15,900,000,000. Of this funding, 32% went to Medicare and 30% to Medicaid.
In 2009 the Centers for Medicare & Medicaid Services (CMS) announced Medicare would begin to cover HIV testing for Medicare beneficiaries who are at increased risk for the infection, including women who are pregnant and Medicare beneficiaries who voluntarily request the service.
Medicare covers HIV testing once every 12 months, or up to 3 times during a pregnancy. Medicare beneficiaries pay nothing for the tests, but generally have a co-pay amount for the doctor visit.
The health reform law (referred to as the “Affordable Care Act” or ACA) that was signed into law in March of 2010 contained some significant reform to Medicare that will impact people with HIV.
The law closes the prescription drug coverage gap in Medicare known as the “donut hole” by 2020.
Additionally, the law incorporated a provision known as “ADAP as TrOOP,” that is very important to the Ryan White ADAP program.
Previously, patients who fell into the Medicare Part D “donut hole” could receive ADAP coverage for their drugs, but the ADAP funding did not count towards the Medicare Part D’s “True Out-of-Pocket” spending limit (TrOOP). Under the new law, ADAP coverage costs count towards TrOOP expenditures starting in 2011.