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Coverage and Reimbursement for HIV Testing


One barrier to promotion of widespread HIV testing is a lack of coverage of, or inadequate reimbursement for testing procedures.
HIV screening among the general population is cost effective and the cost is comparable to other screenings and medical interventions.
Identifying people with HIV disease earlier and connecting them with HIV care and treatment earlier results in better health outcomes for patients and the delivery of more cost effective care.
Historically, HIV screening was not widely covered under most major insurance plans or by government payers. Private insurance is not the primary source of reimbursement for the majority of the providers who treat populations most likely to be infected. Medicaid and other government payers provide coverage for the majority of HIV patients.  
In 2006, the Centers for Disease Control and Prevention (CDC) issued the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings which endorsed making HIV testing a part of routine medical care for people ages 13 to 64 in all healthcare settings. In the recommendations, inadequate reimbursement was identified as a major barrier to implementation routine HIV screening. 
Medicaid is the primary health coverage for the majority of persons living with HIV/AIDS in the U.S. Many private insurance companies base their reimbursement schedule on CMS reimbursements.
Strides have been made in recent years to change both of these issues. AAHIVM has worked tirelessly on the issue, and helps lead an active working group of HIV organizations focused on the issue. 
The U.S. Preventive Services Task Force (USPSTF) is an independent body of experts tasked with providing recommendations to the Federal Government preventive health services. The USPSTF assigns grades to prevention services, and those grades inform federal coverage policies, and also serve inform services under many private insurance plans. In most cases, services graded at an “A” or “B” level are covered.
As of April 2013, the USPSTF recommends the following: 
  • The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. (Grade A) 
  • The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present for labor who are untested and whose HIV status is unknown. (Grade A)
State Medicaid programs have the option of covering HIV testing. However, at present, there is little data on which states offer HIV testing, or reimburse for HIV testing (either for routine testing, or risk-based) and other prevention services.
In 2010, HHS announced a decision to mandate coverage of routine testing as an essential benefit for women covered by Medicaid. Oddly, this actually created an imbalance, where men within the program are not covered for testing at the same level as women.
In 2011, Medicare announced that it would reimburse for HIV Testing for all beneficiaries once a year, and also for pregnant women and those at high risk. HIV testing is also covered under the initial “Welcome to Medicare” visit.
Additional Information: