MEDICARE

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).

Background

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.

Current Status:

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.

HIV Testing:

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.

Health Reform:

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.

OUR ADVOCACY EFFORTS

Letter to Chairman Wyden and Ranking Member Hatch supporting expansion of enhanced Medicaid Reimbursement 09.19.2014
Letter from AAHIVM and the HIV Healthcare Access Working Group offering strong endorsement of the “Ensuring Access to Primary Care for Women & Children Act” (S. 2694)

Letter to Senator Klobuchar 07.10.2013
Letter from AAHIVM and the HIV Health Care Access Working Group to Senator Amy Klobuchar on The Medicare Prescription Drug Price Negotation Act.

Letter to Centers for Medicare and Medicaid Services (CMS) on Dual Eligibility 07.13.12
Letter from AAHIVM and the HIV Health Care Access Working Group to The Centers for Medicare and Medicaid Services (CMS) outlining concerns and goals in serving the dual eligible population.

Letter to Centers for Medicaire and Medicaid Services (CMS) on Reducing Cost of HIV Drugs Under Medicare Part D 10.31.11
Letter from AAHIVM and HIV Health Care Access Working Group to Centers for Medicaire and Medicaid Services (CMS) on Reducing Cost of HIV Drugs Under Medicare Part D.

Fact Sheet on the Early Treatment for HIV Act (ETHA) 2009
A fact sheet developed by AAHIVM and the Health Care Access Working Group on the Early Treatment for HIV Act (ETHA).

Letter to Centers for Medicare and Medicaid Services (CMS) on Allowing AIDS Drug Assistance Programs (ADAPs) to Count Towards True-out-of-pocket costs (TrOOP) Under Medicare Part D Benefit 10.30.09
Letter from AAHIVM and the HIV Community to Centers for Medicare and Medicaid Services (CMS) on Allowing AIDS Drug Assistance Programs (ADAPs) to Count Towards True-out-of-pocket costs (TrOOP) Under Medicare Part D Benefit.

Letter to Chair of House of Ways and Means Urging Rejection of Medicare cuts 09.18.2006
Letter from AAHIVM to Chair of House of Ways and Means urging rejection of proposal cutting payments to physicians under Medicare.

Letter to Centers for Medicare and Medicaid Services (CMS) on the 2007 Draft Guidelines for Formulary Guidance 03.06.2006
Letter from AAHIVM to CMS recommending placement of all antiretrovirals in lowest cost-sharing tier for individual plans in the 2007 formulary guidance.

What You Need To Know About The Medicare Part D Drug Benefit 2006
Questions & Answers on everything you need to know about the Medicare Part D Drug Benefit.

Medicare Part D: What HIV Specialists Need To Know! 2006
A slide presentation by Greg Smiley, Director of Public Policy, on what HIV specialists should know about Medicare Part D.

LEARN MORE

Kaiser Family Foundation – Fact Sheet: Medicare and AIDS HIV Medicare.org