Medicaid already covers some poor HIV patients

Here’s how the programs work

While Medicaid typically does not cover care for all low-income people who have HIV, it does offer coverage in certain states, including Oregon, Florida, New York, and Tennessee. Also, Massachusetts soon will join them with expanded Medicaid coverage for HIV-infected people.

Here’s a look at what those programs cover and how they work:

Florida. Florida has a Medicaid demonstration project that pays for comprehensive health services for an estimated 12,500 Medicaid AIDS and HIV patients. The state’s project also includes a new disease management program that will track continuity of care among about 7,500 Medicaid HIV/AIDS patients.

The state originally had proposed including only AIDS patients in the project, but ultimately decided to cover eligible people who have symptomatic HIV disease, says Fred Goldstein, president of Specialty Disease Management Services of Jacksonville, FL. Goldstein is in charge of implementing the disease management program. (See story about Florida’s new HIV disease management program, p. 6.)

Massachusetts. Massachusetts’ Medicaid expansion, which was passed by the state legislature in November 1999, will provide complete health care coverage for all HIV-positive people who have incomes at or below 200% of the federal poverty level. This amounts to $16,000 per year for a single individual and $32,000 per year for a family of four. The coverage will include primary care services, diagnostic services, prescription drug coverage, mental health care, and substance abuse treatment.

An estimated 2,000 people will have immediate access to the new expanded program, says Joe Carleo, associate director for public policy with AIDS Action Committee of Massachusetts in Boston.

New York. New York’s Medicaid program is expansive, and people infected with HIV who qualify for the medically needy program have been receiving AIDS services since 1986, says Ira Feldman, MPS, deputy director for health care for the AIDS Institute of the New York State Department of Health in Albany.

New York’s program covers HIV-infected patients with incomes of up to 185% of poverty level, which is equal to $15,448 annual income for a single person or $20,802 per year for a household of two. An estimated 50,000 to 70,000 HIV-infected people receive Medicaid coverage, Feldman says.

"We have a full litany of services," he adds. "We have an extremely generous Medicaid package in the state."

The package includes an infrastructure of provi ders, outpatient services, and adherence programs funded through the state’s Medicaid program.

Oregon. Oregon was one of the first states to start a Medicaid waiver program that expands health coverage to all low income residents. Called the Oregon Health Plan (OHP), the program, implemented in 1994, expands Medicaid coverage to all Oregonians living in households below 100% of the federal poverty level, including people who are infected with HIV.

"Oregon Health Plan is a truly innovative approach, one that has accomplished its goal of increasing access to health care," says Mark Loveless, MD, director of the HIV/STD/TB programs of the Oregon Health Division in Portland.

Unfortunately, the program also has been threatened by financial problems, Loveless says. "Because it’s been so successful and because people have accessed it and benefited from its services, it currently is struggling financially."

Data show expanded Medicaid access works

However, state elected officials know how well the program has worked in keeping people healthy, and HIV statistics are the most telling data offering proof, he adds.

"The outcomes that we’ve seen in Oregon have been a dramatic decrease in death rates and a dramatic decrease in AIDS cases since the program began," Loveless says.

One interesting feature of OHP is its focus on prioritizing various diseases and medical conditions. When funding is cut, the plan doesn’t cut potential enrollees through a change in admission criteria. Instead, the plan cuts services according to the prioritized list.

"This plan says, if we can’t afford to take care of all the people who are eligible for all the conditions listed, then we will move the line up so we’re reducing the number of conditions and diagnoses that are covered," Loveless explains. "Explicit rationing of care is based on the prioritized list of medical conditions rather than ration ing care by access barriers."

This has enabled HIV patients to continue to receive the best available treatment and care throughout funding crises. This is because HIV treatment is a relatively high priority on the list.

"Originally, HIV was placed on the list very low because it was viewed as an incurable disease with only palliative care," Loveless says. "And we advocated strongly that antiretroviral therapy, which was in its infancy at the time, was likely to improve and change the natural history of the disease."

HIV disease is listed at 172 on the priority list, which currently is funded partway through the 500s. The first priority list, for example, has conditions such as severe/moderate head injury and insulin-dependent diabetes mellitus as numbers one and two on the priority list. At the other end of the spectrum, dental services for basic prosthetics is listed at 537 and allergic rhinitis and conjunctivitis is listed at 630.

Tennessee. Tennessee was one of the first states to implement a Medicaid waiver program. The state’s program, called TennCare, provides Medicaid coverage to anyone who is uninsured and has an income of 300% or less of the federal poverty level. The service is entirely free to people who have 100% or less of the federal poverty level, and for those who have between 100% and 300% there is a small premium charge, says Drema Mace, director of AIDS Support Services of the Tennessee Department of Health in Nashville.

The state has medical care managers in each of 18 "centers for excellence" across the state. Medical care managers are the point of entry for TennCare enrollees. The managers help HIV patients receive medical services, antiretroviral drugs, and any other health services they might need.

"The medical care manager enters that client into the system, and on the same day they can walk to the pharmacy within that building and pick up their drugs," Mace says. "In the state of Tennessee, if someone needs something related to their HIV care, there’s nothing they can’t get."

About 2,400 HIV-infected people have been enrolled under TennCare.

State officials give the TennCare program some of the credit for the state’s sharp decline in AIDS-related deaths. Those deaths dropped by 23% from 1995 to 1996, by 30% from 1996 to 1997, and by 21% from 1997 to 1998, Mace says.

There have been funding problems, however. "The legislature has appropriated extra dollars to carry it through this year, and they’re working on a plan for how to continue the services," she says.