The number of people with HIV who are enrolled in traditional Medicare has more than doubled since the mid-1990s, increasing from 42,500 in 1997 to 103,400 in 2020. Many more are enrolled in Medicare Advantage plans. This 143% increase is linked to a variety of factors including advancements in antiretroviral treatment leading to longer lifespans and the overall increase in HIV incidence in the country, according to data on 2023 Medicare updates presented by Lindsey Dawson, MA, associate director of HIV Policy and director for LGBTQ Health Policy at Kaiser Family Foundation (KFF).1
More than one-quarter of people living with HIV (28%) are covered by Medicare.2 As the number of patients with HIV continues to rise in the United States, it becomes increasingly important to understand the full scope of services and financial assistance that Medicare and other services can provide. To educate clinicians on 2023 Medicare policy updates, the Association of Nurses in AIDS Care (ANAC) held a webinar on April 12, 2023, titled Medicare and People Living & Aging with HIV Part 3: Salient Policy Issues and Data Updates. Speakers from KFF and the National Alliance of State and Territorial AIDS Directors (NASTAD) discussed pertinent policy issues and data updates.
Medicare Utilization Among People Living With HIV
The 3 main pathways to qualify for Medicare are age, disability status, and disease state for select conditions. Most beneficiaries with HIV (77%) qualify through the disability pathway compared with 22% of beneficiaries overall. Dawson noted that we should expect a change in these statistics in the coming years. “In 2015, 14% of beneficiaries had originally qualified based on age, which increased to 23% as of 2020. This increase reflects advances in HIV treatment that mean people can live longer, healthier lives and disability can be staved off,” she said.
Patients with HIV covered under Medicare are more likely to be male, Black or Hispanic individuals, or younger than 65 years of age when compared with traditional Medicare beneficiaries overall. These demographics closely “mirror the HIV epidemic,” Dawson said.
Comorbidities are also highly prevalent among Medicare beneficiaries living with HIV, particularly behavioral health conditions. Nearly half of Medicare beneficiaries with HIV (47%) are diagnosed with a mental health condition, compared with 29% of beneficiaries overall.
“We also see differences with respect to liver disorders and chronic kidney diseases (CKD), which is especially striking given that it is a younger population,” Dawson said. “There are sharp disparities for viral hepatitis. Approximately 15% of Medicare beneficiaries have a dual diagnosis of viral hepatitis and CKD compared to just 1% of beneficiaries overall who have a viral hepatitis diagnosis,” Dawson added.
Medicare Part B covers physician-administered injectable drugs including antiretroviral treatment and prevention therapies. Beneficiaries who use Part B medications are responsible for 20% coinsurance. However, if they have supplemental coverage (such as Medicaid or Medigap), they may not be subject to this 20% coinsurance.
Medicare Part D covers all approved antiretroviral treatments and prevention because it is 1 of the 6 protected drug classes codified by the Affordable Care Act. While Medicare covers a portion of antiretroviral therapy, many Medicare enrollees still face significant cost-sharing. Part D services will soon be impacted by the Inflation Reduction Act, which included a provision to cap out-of-pocket drug spending at $2000 starting in 2025.
Patients who experience depression from facial wasting (lipoatrophy) caused by antiretroviral treatment are eligible to receive FDA-approved facial lipoatrophy treatments covered under Medicare. This provision was passed in 2010 as this adverse effect “was particularly an issue with some of the older antiretroviral and long-term antiretroviral medications,” Dawson said.
Medicare covers an annual HIV test for beneficiaries aged 15 to 65 years without cost-sharing. People younger than 15 years, older than 65 years with an increased risk, and pregnant beneficiaries are also eligible to receive HIV testing without cost-sharing.
For people who are at an increased risk for HIV, pre-exposure prophylaxis (PrEP) medication is effective in preventing infections. The antiretroviral medications in the PrEP regimen are covered under Part D for oral medications and Part B for physician-administered injectable medications.
Financial Assistance Under Medicare for Beneficiaries With HIV
While Medicare covers a range of services, relatively high cost-sharing requirements exist for many beneficiaries, especially those with HIV. These high costs can be a barrier to care for many patients living with HIV. In addition to Medicare, other financial assistance programs can help patients with access to care. Dori Molozanov, JD, senior manager of Health Systems Integration at NASTAD, highlighted financial assistance programs for people with HIV, specifically emphasizing the Ryan White HIV/AIDS program (RWHAP).3
A substantial number of Medicare beneficiaries living with HIV (61%) are dually eligible for Medicare and Medicaid compared with Medicare beneficiaries overall (18%). Patients can also receive assistance with cost-sharing through the Medicare Part D Low-Income Subsidy (LIS) program. According to 2020 data, 74% of Medicare beneficiaries with HIV were enrolled in the LIS program and those dually enrolled in Medicare and Medicare receive LIS automatically.
The RWHAP helps low-income individuals with HIV access treatments and services. More than half of people with HIV receive services through this program annually. Medicare beneficiaries with HIV enrolled in RWHAP show higher rates of viral suppression than Medicare patients not enrolled in this program (73% vs 58%, respectively).
Although Ryan White Services cover Medicare Parts B, C, and D, Medicare Part A premiums are not allowed because it exclusively covers inpatient care. “As a general rule, inpatient care is not an allowable Ryan White cost payment. Medicare Part B premiums are technically allowed if the program is also assisting with Medicare Part D costs,” Molozanov said.
The RWHAP provides a range of services, from premium and cost-sharing support to covering medications not covered under Medicare. “It’s typical for someone with health coverage, including Medicare, to be a Ryan White and or an AIDS Drug Assistance Program (ADAP) client and to receive wraparound support and services. Medicare would be the primary coverage, and Ryan White would be the last resort that steps in to supplement it when needed,” Molozanov said.
The Future of HIV Care Under Medicare
The Inflation Reduction Act, signed into law on August 16, 2022, included several provisions that would reduce the costs of prescription medications under Medicare starting in 2024. In addition to capping out-of-pocket expenses for prescription medication, this act requires price negotiations of high-cost drugs with the federal government and rebates to be paid to the federal government if drug prices rise faster than inflation.
This act also expanded eligibility for the Part D LIS program, which limits costs for both individuals and the RWHAP and is especially helpful for beneficiaries with HIV who have a modest income.
The future of access to preventative medications and services, such as PrEP, is an emerging topic of discussion as the verdict of Braidwood Management v Becerra restricts the government’s ability to enforce this coverage nationwide.4 “The recent court decision found that in the private market, some preventative services, including PrEP, are no longer required to be covered and [can] not to be required to be covered without cost sharing,” Dawson explained.
While this may raise some concerns for those who rely on Medicare to access PrEP, Dawson said that this matter is “specific to the private market at this time. For something to have an impact on the Medicare program, a separate case would have to be brought with plaintiffs saying that they had suffered harm as a result of the Medicare requirement. So this is certainly something to watch.”
The webinar, which also included a presentation by Nancy Ocheing, MSPH, of KFF, is available online here.
- Dawson L, Ochieng N, Molozanov D. Medicare and People Living & Aging with HIV Part 3: Salient Policy Issues and Data Updates. Presented at: ANAC Webinar; April 12, 2023.
- Dawson L, Kates J, Roberts T, Cubanski J, Neuman T, Damico A. Medicare and People with HIV. KFF. Published online March 27, 2023. Accessed April 18, 2023. https://www.kff.org/hivaids/issue-brief/medicare-and-people-with-hiv/
- HRSA Ryan White HIV/AIDS Program. Program Parts & Initiatives. Last updated December 2022. Accessed April 17, 2023. https://ryanwhite.hrsa.gov/about/parts-and-initiatives
- Levitt L, Cox C, Dawson L, Pestaina K, Salganicoff A, Sobel L. Q&A: Implications of the Ruling on the ACA’s Preventive Services Requirement. KFF. Updated April 4, 2023. Accessed April 18, 2023. https://www.kff.org/policy-watch/qa-implications-of-the-ruling-on-the-acas-preventive-services-requirement/