In May of 2004, the Institute of Medicine (IOM) released a report commissioned by Congress. After evaluating current publicly funded programs for people with HIV/AIDS, they recommended that the federal government step in with a nationally coordinated program to ensure the 950,000 people living with HIV in the United States receive the medical care they need. The committee chair, Lauren LeRoy, said, "Current programs are characterized by limited state budgets, limited services and a confusing array of eligibility requirements -- all of which undermine the nation's goals for preventing and treating HIV/AIDS." The committee recommended an entitlement program funded by the federal government to assure that all HIV-positive low-income Americans would have consistent access to necessary care. This program would establish uniform requirements and a standard set of services across all states. As the report envisions it, the new program would relieve financial strains on state Medicaid programs, allow the federal government to negotiate discounted drug prices as the Veterans Health Administration does and redirect some Ryan White Care ACT funds.
Until there is a coordinated approach to funding medical care for low-income people with HIV/AIDS, such as what was recommended by the IOM, HIV-positive medical consumers need to be familiar with the elements of funding that now exist. Medicare, Medicaid and Ryan White CARE Act monies are the primary public funding sources that allow people with HIV infection to receive care. Benefits and eligibility requirements of these programs vary from state to state and year to year. While it is beyond the scope of this article to explain all the details of these programs, some critical information about them follows.
Medicare is a publicly funded health insurance program covering elderly and several million disabled people, including people with AIDS. These people receive Social Security retirement or Social Security Disability Insurance (SSDI). Medicare is the "primary payer," which means that a provider bills Medicare before looking to any other source of coverage. Not all physicians or clinics accept Medicare as payment.
There are two basic types of Medicare benefits. Part A covers inpatient hospital care, skilled nursing facilities, hospice care and certain types of home health care. Part A does not usually require payment of a premium (monthly charge). People do, however, pay a monthly premium to receive Medicare Part B, which covers doctors' visits, particular laboratory tests and some other limited services. That premium is usually deducted from their monthly check. The premium is currently $66.60 per month. That cost is "updated" annually. Medicare recipients who do not elect to pay for Medicare Part B when they first become eligible for it may pay an increased rate if they enroll later.
In some areas, Medicare recipients are also eligible to elect other types of plans associated with Medicare. These are called Medicare + Choice Plans. If you currently have Medicare and want to explore these options, please refer to the contacts given below. You can also talk with someone in your State Health Insurance Assistance program if you need help weighing options. The toll-free number for Georgia's program is (800) 669-8387. Phone numbers for other State Health Insurance Assistance programs can be obtained at (800) 633-4227.
The absence of Medicare coverage for most prescription drugs has been a great difficulty for medical consumers. Political pressure to ease the burden of skyrocketing pharmaceutical costs has resulted in some recent changes in Medicare benefits for medication coverage. The degree of relief from prescription costs that the program modifications will create is debatable.
Medicare-approved assistance for prescription drugs will be phased in from now until 2006. In the spring of 2004, the Medicare program introduced Medicare-approved drug discount cards that allow people who don't have outpatient prescription drug coverage through Medicaid (see Medicaid section below) to sign up once during a calendar year for a discount drug card. These cards, which are available through a number of private companies, can carry an annual fee of up to $30. The cards allow participants to purchase drugs at discounts determined by each sponsoring company. Interestingly, although recipients are required to remain with their choice of cards for the calendar year (with a limited number of exceptions), the private companies who issue the cards are not required to maintain the discounted prices they originally quote. The value of committing to a particular Medicare-approved discount card can also be compromised if new drugs are prescribed during the calendar year that don't have a discount within that particular card company.
There are many components to consider when weighing the decision to select a new Medicare-approved discount card. Some of these are related to Medicare regulations and some to the business decisions of the private companies that issue the cards. Help in evaluating which -- if any -- Medicare-approved discount card is best for you is available at the Medicare contacts listed below and at www.medicare.gov on the Web (select "Prescription Drug and Other Assistance Programs"). Some consumer publications have found that these discounts don't match the cost-saving of other private discount cards or of ordering drugs by mail from U.S. or Canadian companies.
Medicare recipients who select a Medicare-approved drug discount card may also qualify for up to a $600 credit in the calendar years 2004 and 2005 toward prescription payments. Of course, this is minimally helpful to someone whose costs for combination antiretroviral therapy can run from $10,000 to $12,000 a year.
Questions about Medicare in general, Medicare health plans, Medicare booklets, Medigap policies and assistance programs? Call (800) 633-4227 (800-MEDICARE) or go to www.medicare.gov on the Web.
Medicaid funds come from a combination of federal and state governments. Nationally, Medicaid pays for the largest portion of treatment for low-income people with HIV/AIDS who do not have private health insurance. Financial eligibility requirements, scopes of service and drug formularies (a list of drugs available within a specific program) are established by each state. Medicaid benefits cover hospitalizations, doctor and clinic visits, most prescriptions, very limited dental services and some home health and hospice benefits. As with Medicare, not all physicians or clinics accept Medicaid.
Most people with HIV/AIDS who have Medicaid coverage are eligible for it because they receive Supplemental Security Insurance (SSI), a form of monthly payments based on disability and financial need. Once SSI is awarded, Medicaid follows.
Some people who don't receive SSI also qualify for limited types of Medicaid assistance that pays for Medicare premiums or prescription benefits. Eligibility requirements for these forms of Medicaid may consider income, household size and medical bills. Recipients may need to be reauthorized for eligibility on certain time schedules. In Georgia, application for these and other forms of Medicaid can be made through the local Department of Family and Children Services.
Ryan White CARE Act
Ryan White programs are considered "the payer of last resort." HIV-positive individuals who do not have Medicare, Medicaid or private insurance and meet particular income requirements may qualify for various medical and social services through Ryan White funding. Ryan White funds come from the federal government to support state and local HIV/AIDS programs. As with the other public programs already described, Ryan White funds are allocated by elected state and federal politicians.
The Ryan White CARE Act funds a multitude of programs. Among these are the AIDS Drug Assistance Programs (ADAPs), for which states are required to provide matching funds, and the Health Insurance Premium Payment (HIPP). The HIPP pays the monthly insurance premium for consumers who meet their state's financial eligibility standards. This assists low-income workers who cannot afford the insurance offered through their employers or who lose their jobs and can't pay for the COBRA benefits to which they are entitled.
The discrepancy in available services that was addressed in the IOM report is well-illustrated in ADAPs. ADAPs pay for prescription medications for people with HIV/AIDS who have no other funding source. Nearly 30% of people living with HIV/AIDS in the U.S. are served by ADAPs. The steadily increasing number of HIV-positive people, in addition to new and increasingly expensive HIV medications, strains states' ADAP funds. In May 2004, the Kaiser Family Foundation reported on states' responses to these financial pressures. They found that thirteen state ADAPs had instituted cost-containment measures, including eleven states that closed enrollment to new clients. Nine states reported waiting lists, two states have reduced the number of drugs they offer and three states have some type of per capita expenditure limits.
Each state determines which drugs will be on their formulary and what their eligibility requirements will be to qualify for HIV-related medications through the ADAP program. As of May 2004, the number of drugs on state ADAP formularies throughout the U.S. ranges from 18 to 474. Sixteen state ADAPs did not even cover all the FDA-approved antiretroviral medications. Financial eligibility for ADAPs ran from 125% of the Federal Poverty Level to 500% or higher.
Since access to ADAP and HIPP vary so much across the U.S. and its territories, case managers at Ryan White-funded clinics and social service agencies can be contacted for details on how to access programs in a particular geographical area.
AIDS activists fight frequent battles with their state and federal legislators to keep programs adequately funded to meet the needs of the growing number of people diagnosed with HIV/AIDS. You can let your legislators know what their decisions mean to you through letters, e-mails, phone calls and your vote!