Does Medicare Cover HIV Screenings and Treatment?

Human immunodeficiency virus (HIV) attacks the immune system, opening those living with it to other infections and diseases. The late stages of this condition, when the immune system is badly damaged, is called acquired immunodeficiency syndrome (AIDS). There are currently over 1.2 million Americans living with HIV in the United States. While more than 700,000 have died from complications related to HIV, new treatments and tests have been developed to catch the condition earlier, increasing the lifespan of those infected, and lowering the risk of spreading it to others.

Despite this, there is an estimated 35,000 new cases a year. As the number of cases and the life expectancy of HIV patients grow, the number of HIV patients covered by Medicare also grows. In fact, about a quarter of people with HIV receive health care coverage through Medicare, with the majority qualifying through disability and a growing percentage through age. So, what kind of Medicare coverage is offered for HIV screenings and treatment?

HIV Screenings

Medicare, may cover an annual HIV screening as long as certain criteria are met. Medicare beneficiaries that are pregnant may receive up to three screenings during their pregnancy instead of one annually. If the requirements are met, beneficiaries pay nothing for the test, as long as the health care provider accepts Medicare assignment.

Luckily, according to the Kaiser Family Foundation, the definition of “increased risk for HIV” is defined to include pretty much anybody who asks for a test.

The conditions for coverage are mostly focused on age. Medicare enrollees aged 15 to 65 are eligible for the annual screening. Most people who fit into this category have Medicare through disability. For any beneficiaries younger than 15 or older than 65, an annual screening can be covered, but they’re considered at an increased risk for HIV. Luckily, according to the Kaiser Family Foundation, the definition of “increased risk for HIV” is defined to include pretty much anybody who asks for a test.

HIV Treatment and Medicare

Medicare can assist those with HIV by covering many of the health care aspects of treatment. For any inpatient care needed, Medicare Part A can cover hospital or skilled nursing stays and the treatment that comes with them. Alternatively, Medicare Part B can cover many doctor appointments and other outpatient care including mental health counseling. Medicare Advantage (Part C) offers a combination of these parts and sometimes extra coverage like prescription drugs.

Antiretrovirals are one of six protected drug classes that must be made available to beneficiaries.

Speaking of prescription drugs, the current treatment for HIV comes in the form of antiretroviral therapy (ART). Through a combination of medications, ART can prevent HIV viruses from multiplying and decrease the viral load. This can extend the life expectancy of patients, fight the infection, and lower the risk of transmitting HIV. Unfortunately, these essential medications can be incredibly expensive, costing hundreds to thousands of dollars a month. This is where Medicare Part D or a Medicare Advantage with prescription coverage can help. Antiretrovirals are one of six protected drug classes that must be made available to beneficiaries. While there may still be out-of-pocket costs, a quality Medicare plan can make these medications much more affordable.

Other Federal Programs

Medicare isn’t the only program out there that can help make HIV treatment more affordable. Medicaid offers different programs that can cover a range of services and work with Medicare when the beneficiary is dual eligible. Plans designed specifically for these beneficiaries are Dual Eligible Special Needs Plans (D-SNPs), a kind of Medicare Advantage plan that utilizes both Medicare and Medicaid for more coverage. They can also work together with Medicare Savings Programs (MSPs) and Extra Help for Medicare Part D.

Not every state has one, but many SPAPs offered specialize in HIV and AIDs coverage.

It’s also worth exploring State Pharmaceutical Assistance Program (SPAP). Not every state has one, but many SPAPs offered specialize in HIV and AIDs coverage. These are only a few examples, but there are other federal and non-federal programs designed to help HIV patients afford their treatment.

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HIV can be a scary diagnosis due to the very real danger it can pose and the stigma that comes with it. The financial concerns that can also come with it definitely don’t help either. Thankfully, Medicare and other programs make it easier for beneficiaries to regularly screen for HIV and cover treatment for those who have contracted it.