Published: Oct 01, 2019
Key
Facts
·
Medicaid
is the largest source of insurance coverage for people with HIV, estimated to
cover 42% of the adult population, compared to just 13% of the adult population
overall.1,2
·
The
number of Medicaid beneficiaries with HIV has grown over time as people with
HIV are living longer and new infections continue to occur.3,4 In
2013, there were 282,100 beneficiaries with HIV compared to 212,900 in 2007, a
33% increase. The expansion of the program under the Affordable Care Act (ACA)
has also increased coverage for people with HIV.
·
Medicaid
spending on HIV accounts for 30% of all federal spending on HIV care and it is
the second largest source of public financing for HIV care in the U.S.5
Spending has increased over time, reflecting growing numbers of beneficiaries
with HIV and the rising cost of care.
·
Medicaid
beneficiaries with HIV are more likely to be male, Black, dually eligible for
Medicare and to qualify based on disability, compared to beneficiaries overall.
·
Medicaid
covers a broad range of services, many of which are important for people with
HIV and those at risk, including prescription drugs, inpatient and outpatient
care, and preventive services.
Overview
Medicaid,
the largest public health insurance program in the United States, covering
health and long-term care services for 73 million low-income individuals, has
played a critical role in HIV care since the epidemic began.6,7 It
is the single largest source of coverage for people with HIV in the U.S., and
its role has grown over time as people with HIV are living longer, new
infections continue to occur, and the program was expanded under the Affordable
Care Act (ACA).8,9
Medicaid is estimated to cover 42% of adults with HIV.10 By
comparison, just 13% of adults in the general population are covered by the
program.11
(See Figure 1.)
Figure 1: Insurance Coverage Among People with
HIV and the General Population, 2017
Medicaid
Beneficiaries with HIV
In
2013, there were approximately 282,100 Medicaid beneficiaries with HIV,
compared to 212,900 in 2007 (a 33% increase).12
This number higher today due in part to the ACA’s Medicaid expansion, which has
been a key factor in recent coverage gains among people with HIV.13
While Medicaid is a significant source of coverage for beneficiaries with HIV,
this group represents less than 1% of the overall Medicaid population. The
demographics of Medicaid enrollees with HIV vary significantly from the
demographics of the Medicaid population overall:
·
Medicaid
beneficiaries with HIV are more likely to be male (56% vs. 42%), Black (50% vs.
22%), and between the ages of 45-64 (54% vs. 13%) than the Medicaid population
overall.14
·
A
significant share (30%) are dually eligible for both Medicaid and Medicare,
compared to just 15% of the Medicaid population as a whole; dual eligibles are
among the most chronically ill and costly Medicaid enrollees, with many having
multiple chronic conditions and requiring long-term care.
·
Beneficiaries
with HIV also have a higher prevalence of certain co-morbidities:
o
Fourteen
percent (14%) have a hepatitis diagnosis compared to just 1% of the general
Medicaid population.
o
Half
(48%) have a mental health or substance use disorder diagnosis compared to 19%
of the general Medicaid population (see Figure 2).
o
Figure 2: Diagnosis of Substance Use Disorders
(SUD) & Mental Health (MH) Conditions Among Medicaid Beneficiaries, by HIV
Status, 2013
Medicaid
Eligibility for People with HIV
Most
Medicaid beneficiaries with HIV (65% in 2013) qualify for coverage through a
disability pathway, compared to just 15% of the Medicaid population overall.15 The
remaining share qualify through multiple other mandatory and optional pathways
(see Table 1).
Prior to the ACA, to
qualify for Medicaid an enrollee had to be both low income and “categorically
eligible,” such as being a person with a disability or pregnant. This presented
a “catch-22” for many low-income people with HIV who could not qualify for
Medicaid until they were already quite sick and disabled, despite the fact that
early access to treatment could help stave off disability and significantly improve
health outcomes.
The ACA sought to
fundamentally change this by requiring states to expand their Medicaid programs
to nearly all individuals with incomes at or below 138 percent of poverty
($17,236 for an individual in 2019).16
However, a 2012 Supreme Court ruling on the constitutionality of the ACA
effectively made expansion a state option.17 As
of July 2019, 36 states and Washington, D.C. have adopted the ACA Medicaid
expansion, where two thirds (64%) of people with HIV live. Fourteen states have
not expanded their programs, where 36% of people with HIV live, most of whom
are in Florida and Texas.18
|
Table 1: Medicaid Eligibility Pathways for People with HIV
|
||
|
Category
|
Criteria
|
Mandatory / Optional
|
|
SSI Beneficiaries
|
States must
generally provide Medicaid to those receiving Supplemental Security Income
(SSI) benefits; some states elect the Section 209(b) option to use more
restrictive eligibility criteria. To be eligible for SSI, beneficiaries must
have low incomes (about 73% of the federal poverty level [FPL]), limited
assets, and a significant disability.
|
Generally
mandatory, though as of 2018, 8 are more restrictive Section 209(b) states.
|
|
Children
|
States required to
cover children <19 up to 138% FPL; all states currently cover up to higher
incomes, (upper limits ranging from 175% FPL in ND to 405% FPL in NY).
|
Mandatory
|
|
Pregnant Women
|
States required to
cover pregnant women up to 138% FPL; most cover at higher limits with a
median eligibility level of 205% FPL in 2019
|
Mandatory
|
|
Parent/Caretaker
Relatives
|
States are required
to provide coverage to certain parents (known as Section 1931 parents).
States that have expanded Medicaid fulfill that requirement. States that have
not offer coverage at income thresholds ranging from 17% FPL (TX) to 100% FPL
(WI) in 2019. In addition, three expansion states offer coverage above the
ACA expansion level (IN, CT, & DC).
|
Mandatory for
Section 1931 parents with state option to expand beyond federal income
minimum.
|
|
Low-income Adults
|
ACA expansion group
for adults under 65 years old up to 138% FPL, regardless of disability
status.
|
Mandated by ACA;
effectively state option due to SCOTUS ruling.
(37
states offer coverage, 14 do not as of July 2019)
|
|
Seniors and Persons
with Disabilities up to 100% FPL
|
State option to
provide Medicaid to seniors and people with disabilities whose income exceeds
SSI limits, up to 100% FPL.
|
Optional (21 states
in 2018)
|
|
Medically Needy
(MN)
|
State option to
extend Medicaid to those who meet categorical eligibility, such as disability
status, but need to “spend down” by incurring medical expenses to meet
state’s income criteria.
|
Optional
(34
states as of 2018)
|
|
Buy-in for Working
People with Disabilities
|
State option to
provide Medicaid to working individuals with disabilities at higher
income/asset limits. Limits and income related premiums/cost-sharing vary by
state (median 250% FPL in 2015).
|
Optional
(45
States as of 2018)
|
|
SOURCES: Kaiser
Family Foundation. State Health Facts. https://www.kff.org/state-category/medicaid-chip/;
Musumeci, M., et al. Kaiser Family Foundation. Medicaid Financial Eligibility
for Seniors and People with Disabilities: Findings from a 50-state Survey,
2019. https://www.kff.org/medicaid/issue-brief/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey/
|
||
Medicaid
Spending on HIV
Medicaid
is a means-tested entitlement program, jointly financed by the federal and
state governments. In the traditional (non-expansion) program, the federal
government matches state Medicaid spending at rates ranging from 50% to 77%
(using a formula based on state per capita income).19 Under
the ACA, the federal match for the expansion population is higher. It began at
100% in 2014, and is phasing down to 90% in 2020 and thereafter.
In FY 2019, federal
Medicaid spending on HIV is estimated to total $6.3 billion, accounting for 30%
of all federal spending on HIV care and representing the second largest source
of public financing for HIV care in the U.S, after Medicare (see Figure 3).20 In
addition, the states’ share of Medicaid spending on HIV was estimated to be an
additional $3.8 billion in FY 2019.21
Medicaid spending on HIV has increased over time, reflecting growing numbers of
beneficiaries with HIV and the rising cost of care and treatment. Between 2013
and 2019, federal Medicaid spending on HIV increased by 60%, rising from $3.97
billion to $6.3 billion.22
Still, in FY 2019 federal Medicaid spending on HIV represents less than 2% of
total federal Medicaid spending.
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Figure
3: Federal Funding for HIV/AIDS Care in the U.S., by Program, FY 2019
Medicaid beneficiaries
with HIV have different spending patterns than beneficiaries overall, and
spending on HIV treatment, due to the high cost of HIV medications, has an
outsized impact on the program:23,24
- Average annual
per capita spending on Medicaid beneficiaries with HIV was $23,551 in
2013, about four times that of Medicaid beneficiaries overall ($5,871).25,26
- While less than
half of one percent of Medicaid beneficiaries have HIV, 8% of all Medicaid
drug spending is on antiretrovirals (the drugs used to treat and prevent
HIV).27
Medicaid
Benefits
Medicaid
covers a broad range of services, many of which are important for people with
HIV and those at risk. Medicaid benefits are offered on a fee-for-service
basis, through capitated managed care organizations (MCOs), or through a
combination of these benefit designs.28
In some cases, people
with HIV may not have access to all the health services needed to stay healthy
through Medicaid alone and rely on supplemental coverage from other payers or
programs, including the Medicare program for those who are dually eligible and
the Ryan White HIV/AIDS Program, the federal grant program for people with HIV
who are uninsured and underinsured.
While most states that
have expanded their Medicaid programs have fully aligned the benefits in their
traditional program with the benefits for the expansion population, there are
technically different requirements between the two, with potential implications
for HIV care and prevention.
Though many states elect
not to impose any, states are permitted to require “nominal” cost-sharing by
some groups of beneficiaries; other groups and services are exempt altogether.
Traditional
Medicaid Programs
Under traditional
Medicaid, states must cover certain mandatory services, specified in federal
law, in order to receive federal matching funds, though they have some
flexibility in determining the scope of services.29 (See
Table 2.)
|
Table 2: Traditional Medicaid Service Categories
|
|
|
Required Services
Include:30
|
Optional Services
Include:31
|
In addition to the above,
traditional Medicaid programs also cover preventive services including ones
that are important to people with HIV:
·
Programs
must cover “medically necessary” HIV testing (i.e. indicated due to risk) and
may cover routine HIV testing (screening regardless of risk). As of 2015, 42
states and DC report covering routine HIV testing while eight only cover
medically necessary testing.32,33
·
States
must also cover pre-exposure prophylaxis (PrEP), the drug used to prevent HIV
among those at increased risk.
·
Under
the ACA, states are incentivized to cover a full suite of preventive services,
including routine HIV testing and PrEP (starting in 2021), without cost-sharing
in exchange for a 1% increase in the federally matching rate for those
services.34 As
of June 2019, 15 states have approval from CMS for this increase in exchange
for offering these services without cost-sharing.3536
Medicaid
Expansion Programs
Most
enrollees who gain access to Medicaid through the ACA expansion receive the
same benefits as traditional enrollees. However, there are technical
differences and expansion enrollees must receive services that fall into the
ACA’s ten “essential health benefit” (EHB) categories, many of which are
important for HIV care (see Table 3):
|
Table 3: Essential Health
Benefit Categories
|
|
Benefits within these
categories are largely defined through a state-based benchmarking process using
a plan of the state’s choosing from federally mandated options or from an
alternative plan through a waiver. Most states have used a waiver to select the
traditional state Medicaid plan as the benchmark and align traditional and
expansion benefits.37
Preventive services are unique in that they are specifically defined to include
services receiving an “A” or “B” rating from the United States Preventive
Services Task Force (USPSTF), including routine HIV screening and PrEP, which
must be offered without cost-sharing.
Medicaid
Health Homes
The ACA
also gave states a new option to provide Medicaid health home services to
enrollees with chronic conditions (and receive a temporary enhanced federal
match of 90% for the first two program years). Health homes encompass a range
of services designed to help manage care for those who are chronically ill,
such as comprehensive care management and care coordination. The law named
several chronic conditions that could be targeted for health homes, and CMS
considers others, including HIV, for states pursuing this option. As of March
2019, 38 health homes had been approved in 23 states and the District of
Columbia. Among these, four states (WA, AL, MI, and NC) included HIV among
other qualifying conditions for enrollment into the health home and one state,
Wisconsin, designed a health home specifically targeted at beneficiaries with
HIV/AIDS.38
Waivers
States
also have the ability to seek waivers from certain Medicaid requirements. With
approval from the federal government, states are permitted to use Section 1115
Medicaid demonstration waivers to experiment with approaches to delivering
program benefits in ways that differ from what is allowed under statute, and
could impact people with HIV. While waivers are not new to the program, under
the Trump administration, CMS has certified waivers that have not been
permitted by prior administrations, including those predicating Medicaid
benefits on work requirements. Other recent waivers allow for purchasing of
marketplace health plans for the expansion population, increasing cost-sharing,
providing additional benefits or offering benefits to new populations (e.g.,
substance use treatment, family planning, etc.), and transforming how care is
delivered or paid for.
States also have the
option to apply for a “home and community-based services (HCBS)” waiver.
Medicaid HCBS waiver authorities include Sec. 1915 (c) and Sec. 1115, both of
which allow states to expand financial eligibility and offer HCBS to seniors
and people with disabilities who would otherwise qualify for an institutional
level of care. HCBS waivers have been important for people with HIV and are used
by several states to serve this population. As of 2017, 10 states had an HCBS
designed specifically for or to include people with HIV, serving over ten
thousand people with HIV.39,40
Future
Outlook
As the
single largest source of health coverage for people with HIV, Medicaid has
played a significant role for this population since the HIV epidemic began and
its role has continued to grow. In particular, many low income people with HIV
who could not previously qualify for Medicaid because they did not meet
categorical eligibility criteria, such as disability, have gained access under
the ACA. Going forward, it will be important to continue to monitor the impact
of Medicaid coverage on people with and at risk for HIV, particularly given
that several states are still deciding whether to expand their programs. In
addition, assessing the impact of waivers will be important as states seek to
offer coverage with different eligibility requirements than has previously been
permitted. Early research has shown that some demonstrations, such as work
requirements, may increase churn in the program, which could have particularly
significant consequences for people who rely on access to care and treatment
for survival.41 In
addition, in order to harness the benefits of “treatment as prevention” (i.e.
when someone with HIV has an undetectable viral load, achieved through use of
antiretroviral treatment, HIV cannot be transmitted), it is important to ensure
that people with HIV can remain in coverage and engage in care and treatment.
Endnotes
1. Centers for Disease
Control and Prevention. Behavioral. Medical Monitoring Project, United States,
2017 Cycle.
2. Kaiser Family Foundation
analysis of American Community Survey data, 2017.
3. Kaiser Family Foundation.
State Health Facts. Medicaid Enrollment and Spending on HIV/AIDS.
(FY07-FY11). http://kff.org/hivaids/state-indicator/enrollment-spending-on-hiv/.
4. Kates, J. and Dawson, L.
Kaiser Family Foundation. Insurance Coverage Changes for People with HIV
Under the ACA. 2017. https://www.kff.org/health-reform/issue-brief/insurance-coverage-changes-for-people-with-hiv-under-the-aca/.
5. Kaiser Family Foundation.
U.S. Federal Funding for HIV/AIDS: Trends Over Time. March 2019. https://www.kff.org/hivaids/fact-sheet/u-s-federal-funding-for-hivaids-trends-over-time/.
6. CMS. March 2019 Medicaid
& CHIP Enrollment Data Highlights. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html.
7. Kaiser Family Foundation.
State Health Facts. Total Monthly Medicaid and CHIP Enrollment. December 2018. https://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
8. Kaiser Family Foundation.
State Health Facts. Medicaid Enrollment and Spending on HIV/AIDS.
(FY07-FY11). http://kff.org/health-reform/state-indicator-enrollment-spending-on-hiv.
9. See current status of
state Medicaid expansion decisions: http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
10. Centers for Disease
Control and Prevention. Behavioral. Medical Monitoring Project, United States,
2017 Cycle.
11. Kaiser Family Foundation
analysis of American Community Survey data, 2017.
12. Kaiser Family Foundation
analysis of Medicaid Statistical Information System (MSIS) data, 2007-2013.
13. Kates, J. and Dawson, L.
Kaiser Family Foundation. Insurance Coverage Changes for People with HIV
Under the ACA. 2017. https://www.kff.org/health-reform/issue-brief/insurance-coverage-changes-for-people-with-hiv-under-the-aca/.
14. Kaiser Family Foundation
analysis of Medicaid Statistical Information System (MSIS) data, 2013.
15. Kaiser Family Foundation
analysis of Medicaid Statistical Information System (MSIS) data, 2013.
16. U.S. Department of Health
and Human Services, Office of The Assistant Secretary for Planning and
Evaluation, 2019 Poverty Guidelines. Available at: https://aspe.hhs.gov/poverty-guidelines.
17. Kaiser Family Foundation.
A Guide to the Supreme Court’s Affordable Care Act Decision. 2012.
Available at: http://kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-affordable/.
18. Kaiser Family Foundation.
State Health Facts. Status of State Action on the Medicaid
Expansion Decision. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act;
Kaiser analysis of data from State Health Facts and the CDC Atlas.
19. Kaiser Family Foundation.
State Health Facts. Federal Medical Assistance Percentage (FMAP) for
Medicaid and Multiplier. http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/.
20. Kaiser Family Foundation.
U.S. Federal Funding for HIV/AIDS: Trends Over Time. http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-trends-over-time/.
21. Kaiser Family Foundation
CMS correspondence.
22. Kaiser Family Foundation
analysis of budget data provided by CMS via a special data request.
23. All spending detailed in
this section is for fee-for-service Medicaid only.
24. Per person drug spending
is calculated based on data from FFS beneficiaries only as the numerator and
all beneficiaries as the denominator due to limitations with MSIS.
25. Kaiser Family Foundation
analysis of Medicaid Statistical Information System (MSIS) data, 2013.
26. Kaiser Family Foundation
analysis of Medicaid Statistical Information System (MSIS) data, 2013.
27. Young, K. Kaiser Family
Foundation. Utilization and Spending Trends in Medicaid Outpatient
Prescription Drugs. 2019. https://www.kff.org/medicaid/issue-brief/utilization-and-spending-trends-in-medicaid-outpatient-prescription-drugs/.
28. Recognizing the high cost
of drugs, especially those used for treating certain conditions, such as HIV,
some states “carve-out” prescription drug benefits from these plans, instead
using their fee-for-service program to deliver this benefit. Of the 38 states
that deliver some care through MCOs, 5 (CO, GA, MT, TN, WV) carve-out all
prescription drugs and 4 (CA, MD, MI, and DC) specifically carve-out
antiretrovirals used to treat HIV. See CMS. “Medicaid Drug Utilization Review
State Comparison/Summary Report FFY 2017 Annual Report Prescription Drug
Fee-For-Service Programs”. October 2018. https://www.medicaid.gov/medicaid/prescription-drugs/downloads/drug-utilization-review/2017-dur-summary-report.pdf.
29. CMS. Mandatory and
Optional Medicaid Benefits. https://www.medicaid.gov/medicaid/benefits/list-of-benefits/index.html
30. Kaiser Family Foundation.
Medicaid Moving Forward. 2015. http://kff.org/health-reform/issue-brief/medicaid-moving-forward/.
31. Kaiser Family Foundation.
Medicaid Moving Forward. 2015. http://kff.org/health-reform/issue-brief/medicaid-moving-forward/.
32. AL, FL, GA, ME, MS, NE,
SD, and VA.
33. Kaiser Family Foundation.
HIV testing in the U.S. June 2019. https://www.kff.org/hivaids/fact-sheet/hiv-testing-in-the-united-states/.
34. Kaiser Family Foundation.
HIV Testing in the United States, 2016. http://kff.org/hivaids/fact-sheet/hiv-testing-in-the-united-states/.
35. CA, CO, DE, HI, KY, LA,
MT, NH, NJ, NV, NY, OH, OR, WA and WI.
36. Kaiser Family Foundation
personal communication with CMS.
37. Baumrucker, E.
Congressional Research Service. Medicaid Alternative Benefit Plan Coverage:
Frequently Asked Questions. R45412. November 26, 2018. https://www.everycrsreport.com/reports/R45412.html.
38. CMS. State-by-State
Health Home State Plan Amendment Matrix. March 2019. https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-home-information-resource-center/downloads/state-hh-spa-at-a-glance-matrix.pdf.
39. Musumeci, M. and Watts,
M. Kaiser Family Foundation. Key State Policy Choices About Medicaid Home
and Community-Based Services. 2019. http://files.kff.org/attachment/Issue-Brief-Key-State-Policy-Choices-About-Medicaid-Home-and-Community-Based-Services.
40. Musumeci, M.,
Chidambaram, P. and Watts, M. Kaiser Family Foundation. Medicaid Home and
Community-Based Services Enrollment and Spending. 2019. https://www.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-spending/.
41. See for example:
Rudowitz, R., M., Musumeci , and C., Hall. Kaiser Family Foundation. State
Data for Medicaid Work Requirements in Arkansas. 2019. https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/.
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