Medicare Part D plans are required to cover a range of HIV medications.
One of the most common treatments for HIV is the use of antiretroviral therapy (ART); while these drugs are typically covered, they can still be pricey for Medicare beneficiaries.
Medicare also covers medications that don’t treat HIV but may be part of your treatment, such as painkillers and antidepressants.
You may qualify for HIV treatments through Medicare if you’re younger than 65 but qualify for Social Security Disability Insurance for 24 months.
Yes, Medicare provides coverage for those with Human Immunodeficiency Virus, commonly known as HIV. But like the disease itself, covering it can be complicated. If you’re 65 or over and living with HIV, there are some important questions you’ll need answered. Are there HIV drugs covered by Medicare? How does Medicare pay for HIV medication?
Here’s what you need to know about HIV and Medicare.
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There is no cure for the virus that causes HIV and AIDS, but there are a host of HIV drugs covered by Medicare that can have some encouraging effects. These drugs work by keeping your body’s viral load low. This decrease in the amount of virus in your body allows it to fight infections, make you feel healthier and even lessen the risk of spreading it to partners. In some cases, regular prescribed HIV drugs covered by Medicare have even slowed or stopped symptoms. Most of these drugs are antiretroviral therapy (ART) because they fight the retrovirus that causes HIV.
Part D HIV coverage
How does Medicare pay for HIV medication? The answer — when that medication is prescribed and taken outside of a medical facility — is that it’s covered under Part D. Also called Medicare Prescription Drug Plan, Part D helps pay for Medicare beneficiaries’ medications. Private insurance companies sell part D plans. Each company has a list of the drugs it covers in a drug formulary. Prescription drug formularies break up the types of drugs by tiers. The top tiers typically include brand-name drugs with the highest price tags; generics and other lower-cost options occupy the lower tiers. While insurance companies are allowed some freedom in how their drugs are classified and priced, every Part D plan must cover “all or substantially all” drugs in the antiretroviral class, according to the Centers for Medicare & Medicaid Services.
If you have Original Medicare (Parts A and B), you must add Part D separately. You will also pay a separate premium, deductible and copayments for this coverage.
As we mentioned, Medicare must cover the antiretroviral medications that help treat HIV. The Rx drugs for HIV spread across seven different classes that work similarly, have the same approved use, or share other characteristics. Does Medicare cover HIV medication found in all seven antiretroviral categories? Yes; if you have HIV and are on Medicare, it will cover drugs found in the following seven classes:
- CCR5 antagonists
- Fusion inhibitors
- Integrase Strand Transfer Inhibitors (INTSIs)
- Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
- Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
- Post-Attachment inhibitors
- Protease Inhibitors (PIs)
There are other treatments not listed above that your doctor may choose to use for your treatment. While most HIV treatments are covered by Medicare, discuss any concerns you have with your doctor and your Part D insurance company.
Medicare can also help pay for other medications your doctor prescribes as part of your treatment. Doctors often include painkillers and anti-nausea medications, among others, to help ease symptoms associated with HIV-based medical care. While they don’t treat HIV itself, Medicare Part D will cover these prescription drugs to help with the mental and physical effects of an HIV diagnosis and treatment.
But if you’ve been diagnosed with HIV, medication is probably just a part of your overall care plan. Instead, you may need the other parts of Medicare to kick in and cover various aspects of your healthcare needs. That can include inpatient stays, doctor’s visits and even preventive services like screenings.
How does Medicare cover HIV treatment if your care extends past just medications? If you have Original Medicare, Part A and Part B cover much of your inpatient and outpatient care. Your Part D coverage is a separate plan from Original Medicare. On the other hand, Medicare Advantage (Part C) provides at least the same level of care as Parts A and B and bundles Part D coverage. Here’s how each part of Medicare works to cover HIV treatments.
Part A HIV coverage
Medicare Part A provides coverage for beneficiaries who need inpatient care, including stays in a hospital or skilled nursing facility if needed during HIV treatments. Each of these settings offers different levels of care and charge their own out-of-pocket costs, usually in the form of daily coinsurance. Coinsurance is what you pay out of pocket after Medicare Part A pays its portion of approved costs.
Medicare covers your first 60 days in a hospital per benefit year. If your HIV treatments require a stay in a skilled nursing facility, your first 20 days are covered. After you reach either threshold, you’ll pay daily coinsurance rates.
Part B HIV coverage
Medicare Part B provides an array of HIV-related benefits. Here are a few examples:
- HIV screening: Though Medicare is for those age 65 and older, Part B covers one HIV screening per year for all Americans aged 15-65 as a preventive service. If you’re over 65 and have an increased risk of HIV, Part B will also cover your screening.
- Durable medical equipment (DME): As with other conditions, HIV may require medically necessary equipment as part of your treatment, including mobility devices like a cane or wheelchair, specialized and therapeutic equipment.
- Medical services: Part B provides the medical coverage portion of Medicare. It will help pay for the doctor visits and lab work you may need as part of your treatment.
Medicare Advantage HIV coverage
Medicare Advantage plans, or Part C, replace Original Medicare (Part A & B) but offer the same Part A and B benefits or coverage as Original Medicare. Along with receiving Part A and B benefits, Medicare Part C often bundles additional valuable services for beneficiaries with HIV, including dental and prescription drug coverage. Another key difference between Medicare Advantage and Original Medicare is that Part C plans include an out-of-pocket maximum; once you meet this threshold for the year, your insurer will pay the remainder of your costs. Original Medicare does not cap the amount beneficiaries can pay out of pocket in a year.
Medigap HIV coverage
Medicare Parts A and B provide excellent coverage but can be a financial burden, especially considering Original Medicare does not include an out-of-pocket maximum. Original Medicare beneficiaries can add Medicare Supplement Insurance (Medigap) to help cover Part A and Part B costs like deductibles and coinsurance. A Medigap plan comes with an extra premium to pay, but the monthly cost of coverage is typically significantly less than the costs associated with prolonged care.
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The type of care and medication regimen required to treat HIV dictate the majority of costs. HIV treatments are among the most costly for chronic conditions, with various medications ranging from hundreds to thousands of dollars per supply. Americans spent $22.5 billion on antiretroviral drugs for HIV in 2018.
If you need HIV medication but are having trouble affording your copays, you may qualify for a Part D low-income subsidy called Extra Help. This federal program can help you pay for your Part D premium, deductible and copays if you are eligible.
Depending on the type of Medicare you have, a good portion of your HIV treatments may be covered by your plan. There are some key differences in how each covers the services you’ll need and how much they’ll pay.
Original Medicare (Parts A and B)
Medicare Part A includes a no-cost premium if you worked long enough to qualify. It also covers a set number of inpatient days for different conditions, after which you’ll be responsible for paying various daily coinsurance rates. Part B typically pays 80% of medically necessary medical treatments after you meet your annual deductible, leaving you with the remaining 20% coinsurance. Part B also fully covers several preventive services.
Medicare Part D
Since HIV treatments are largely medication-based, Part D will likely provide much of your coverage. How does Medicare cover HIV drugs in your Part D plan? As we mentioned above, Part D plans are sold by private insurers. Each of these companies has its list of covered drugs, called a formulary. The formularies categorize medicines into different tiers. To find out how much your Part D plan covers for your HIV medications — and how much you’ll pay — find them in your plan’s drug formulary. If you need help finding your medication, call your insurer.
Medicare Advantage plans must provide at least the same level of care as Original Medicare for healthy individuals and people living with a chronic disease, e.g., HIV. Part C plans can vary from Original Medicare, especially when it comes to costs. While beneficiaries pay 20% coinsurance for Part B services, Part C plans often feature flat-rate copayments. Medicare Advantage also can offer out-of-pocket maximums and bundle Part D coverage.
Dual eligibility: Medicare and Medicaid
Like other chronic conditions, HIV may prohibit a person from working, making them unable to afford their treatments. If you’re 65 or older and can’t afford your medical care, you may be able to also qualify for Medicaid. This is a federal program run by the states that helps provide financial assistance for medical care. If you’re dual eligible, Medicaid and Medicare will work together to cover most of your medical bills and prescription drug costs. Nearly 70% of Medicare beneficiaries with HIV are dual-eligible.
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Yes — if you’re diagnosed with HIV, Medicare can provide your coverage, even if you’re younger than 65. If your diagnosis keeps you from working, you may qualify for Social Security Disability Insurance. According to the Social Security Administration, qualification for SSDI depends on a few details:
- Your condition keeps you from working
- Your condition is expected to last at least 12 months or result in death
An HIV diagnosis does not mean you’ll automatically qualify for SSDI. The Social Security Administration makes disability determinations for HIV on a case-by-case basis. You’ll need to provide some key information, including medical history and dates of diagnosis and onset of symptoms.
Does Medicare cover HIV meds if I’m younger than 65? As with the medical services covered by Parts A and B, you also will qualify for Part D coverage if you’re younger than 65 but are qualified for SSDI.
When you get sick, your body’s immune system produces cells to fight the infection. Human Immunodeficiency Virus, or HIV, is a retrovirus that attacks those cells and leaves you open to potentially deadly infections that your body would otherwise be able to fight off. HIV generally spreads through the blood. If the condition progresses far enough, a patient may be diagnosed with an advanced form of HIV known as Acquired Immunodeficiency Syndrome (AIDS).
Still not sure if Medicare covers your HIV-related services? Give GoHealth a call. Our licensed insurance agents can look up your medications, discuss your needs and evaluate your current plan. Then we’ll see if other options fit your needs.
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