Last year, the Inflation Reduction Act was signed into law, bringing forth significant changes to Medicare coverage for beneficiaries with HIV. It is crucial that Medicare beneficiaries with HIV are counseled about the upcoming modifications that may affect their healthcare benefits.
On July 19, 2023, the Association of Nurses in AIDS Care (ANAC) hosted a webinar where representatives from the Access, Care, and Engagement Technical Assistance (ACE TA) Center addressed the topic of navigating Medicare coverage and relevant policy updates.1 The ACE TA Center plays a pivotal role in supporting individuals enrolled in the Ryan White HIV/AIDS Program (RWHAP) by helping them understand and optimize their healthcare coverage.2
As the largest federally funded program for people living with HIV, the RWHAP ranks third after Medicare and Medicaid in providing essential treatment and management services for HIV.3
“We support Ryan White grantees to engage, enroll, and retain clients in Medicare, Medicaid, and individual health insurance options. We also aim to build organizational health insurance literacy, thereby improving clients’ capacity to use the health care system and to communicate with clients about how to stay enrolled and use health coverages,” Leisl Lu, senior consultant at John Snow, Inc (JSI) and technical advisor for the ACE TA Center stated.
Original Medicare for Individuals With HIV
While there are multiple parts to Medicare, the only 2 options to get coverage is through Original Healthcare or Medicare Advantage.
To be eligible for Medicare, a person must be a US citizen or legal resident for at least 5 years, with some exceptions. There are a few ways that people with HIV can qualify for Medicare:
- Individuals can qualify by aging into Medicare when they turn 65 years old
- Individuals under 65 years of age can qualify if they have a disability or end-stage renal disease.4
Original Medicare coverage includes Medicare Part A, which covers inpatient hospital care, and Part B which covers physician services. Original Medicare does not include Part D, which covers outpatient prescription medications, including HIV antiretroviral drugs and some recommended vaccines.
There are some cases where a Medicare beneficiary does not need to pay a premium for Medicare Part A. To qualify for premium-free Part A, an individual must have at least 40 quarters of Social Security work credits. To earn work credits, a person can work in a job that pays toward Social Security taxes. They can earn 1 credit per quarter and a maximum of 4 credits in 1 year.
“Forty credits equals about 10 years’ worth of work. These credits do not need to be earned consecutively either. If you don’t have enough credits by the age of 65, you can still enroll in Medicare Part A, but you may have to pay a premium for Part A coverage. The premium amount varies depending on how many credits you have so far,” Lu added.
Original Medicare grants you access to a nationwide network of providers. Enrollment costs and coverage are determined by the federal government, so costs are the same regardless of which state you reside in.
Medigap Supplemental Insurance
With Original Medicare, there are some coverage gaps that beneficiaries should be aware of. For example, Medicare Part A has a deductible based on a 90-day benefit period, which means it can be applied for up to 4 times in a year where an individual must pay for Medicare coverage.
“Even after you’ve met the deductible, you could still face additional charges for long-term hospitalizations, skilled nursing care, and blood products,” Christine Luong, a consultant at JSI and a research and policy associate at the ACE TA Center stated.
For Medicare Part B, the deductible is based on an annual benefit period. However, after an individual has met their deductible, Medicare will only pay for 80% of all approved charges, leaving the beneficiary responsible for the remaining 20%.
To help address some of these coverage gaps in Original Medicare, some Medicare supplemental services are available. These supplemental plans, also referred to as Medigap, are sold by private insurance companies and their coverage and benefits are standardized by the state and federal laws.
“It’s also important to know that Medigap plans do not include prescription drug coverage. They are not going to help with any copays, deductibles, or co-insurance related to prescription drug coverage,” Luong added. “If you have Original Medicare and you still need drug coverage, that has to be purchased separately.”
There are 10 different Medigap plans and the monthly premiums vary per state and plan type. For reference, monthly Medicare premiums can range from “under a hundred dollars to over a thousand dollars,” Luong stated. This premium would be in addition to the Medicare Part A premium or Part B premium.
There are some limitations to Medigap plans, such as not covering long-term care, vision or dental services, and potentially still having to pay some out-of-pocket costs. However, Medigap plans may still be beneficial for “people who have more complex medical needs or people who travel during the year and anticipate needing to see a provider outside of the country,” Luong emphasized.
Medicare Advantage plans bundle Medicare Part A and Medicare Part B, and in most cases, Medicare Part D prescription drug coverage. Luong added that “this year in 2023, the average cost of a Medicare Advantage plan premium was $18, but many of these plans have $0 premiums.”
For patients enrolled in the RWHAP, the AIDS Drug Assistance Program (ADAP) can help beneficiaries pay the Medicare Advantage premium on top of the monthly Medicare Part B premium. Additionally, Medicare Advantage can offer extra benefits that Original Medicare does not, including vision, dental, hearing, and wellness programs. These services are administered by private insurance companies and can vary from state to state.
While Medicare Advantage has benefits, this plan might not be fit for all people with HIV.
“Advantage plans are not always the best choice for people with HIV because they usually have more limited provider networks. This might make it harder for someone with complex physicians to continue seeing their existing providers who might not all be in the same network. This is why most Ryan White programs recommend that their clients enroll in Original Medicare,” Luong stated.
Medicare Part D or Prescription Drug Coverage
There are 2 ways to access prescription drug coverage through Medicare:
- Enrolling in Original Medicare, which includes Part A or Part B, and purchasing an optional Medicare Part D prescription drug coverage plan;
- Enrolling in a Medicare Advantage plan that bundles prescription drug coverage along with Part A and B coverage.
Medicare Part D covers all FDA-approved antiretroviral treatments for HIV and prevention, as it is 1 of the 6 protected drug classes through the Affordable Care Act.
However, there are still some restrictions for non-HIV medications through Part D, including quantity limits and non-formulary medications. “We found that often, providers can generally work with a Part D plan insurance carrier to request a prior authorization or exception that overrides these restrictions to accessing some of the non-HIV medications,” Lu said.
Because Medicare Part D premiums can be expensive, Lu encouraged individuals to “find out if you’re eligible for the Federal Extra Help program, which helps people with limited income and resources to pay for some or all of your Medicare prescription drug program costs like premiums, deductibles, and co-insurance.”5
The Future of Coverage for HIV Treatment and Prevention
There are currently 2 levels of assistance, full and partial extra help, for the Federal Extra Help program. Due to the Inflation Reduction Act, these levels of assistance will be eliminated starting in January 2024.
“Anyone with incomes at or below a hundred percent of the federal poverty level will get full extra health benefits,” Lu stated. This change will expand the Extra Help program benefits to many more individuals.
For patients with Medicare Part D in particular, the Inflation Reduction Act will reduce the coverage gaps and Medicare will pay more total drug costs compared to previous years. “Based on what we’ve been reading about the Inflation Reduction Act, it’s really going to go a long way in making sure that people are paying less out of pocket,” Luong adds.
Beginning in 2024, the Inflation Reduction Act is set to cap out-of-pocket spending for people enrolled in Medicare Part D at $3250. In 2025, there will be a hard cap on out-of-pocket spending at $2000.6
For more Medicare coverage updates for people with HIV, click here.
1. Lu L, Luong C. A How to Guide: Medicare Enrollment for Adults Living with HIV (part 2). Presented at: ANAC Webinar; July 19, 2023.
2. Target HIV. ACE TA Center. Accessed July 24, 2023. https://targethiv.org/ace
3. The Ryan White HIV/AIDS Program: The Basics. KFF. Published online November 3, 2022. Accessed July 24, 2023. https://www.kff.org/hivaids/fact-sheet/the-ryan-white-hivaids-program-the-basics/
4. Who’s eligible for Medicare? US Department of Health and Human Services. Last Updated December 8, 2022. Accessed July 24, 2023. https://www.hhs.gov/answers/medicare-and-medicaid/who-is-eligible-for-medicare/index.html
5. Apply for Medicare Part D Extra Help program. Social Security Administration. Accessed July 24, 2023. https://www.ssa.gov/medicare/part-d-extra-help
6. Cubanski J, Neuman T, Freed M. Explaining the Prescription Drug Provisions in the Inflation Reduction Act. Published online January 24, 2023. Accessed July 24, 2023. https://www.kff.org/medicare/issue-brief/explaining-the-prescription-drug-provisions-in-the-inflation-reduction-act/#bullet06