Does Medicare Cover HIV Treatment?
Key Takeaways
- Medicare Part D plans are required to cover a range of HIV medications.
- One of the most common treatments for HIV is antiretroviral therapy (ART).
- 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.
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.
Here’s what you need to know about HIV and Medicare.
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What Is HIV?
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).Are HIV Medications Covered by Medicare?
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? For drugs you take outside of a medical facility, you will need a Medicare Part D prescription drug plan. Private insurance carriers sell part D plans. Each company has a list of the drugs it covers in a drug formulary. Prescription drug formularies organize medications into 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.HIV medications
There are seven different classes of Rx drugs for HIV that work similarly, have the same approved use, or share other characteristics. If you have HIV have a Medicare Part D plan, it will cover drugs in each of these classes:- CCR5 antagonists
- Fusion inhibitors
- Integrase Strand Transfer Inhibitors (INTSIs)
- Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
- Nucleotide Reverse Transcriptase Inhibitors (NRTIs)
- Post-Attachment inhibitors
- Protease Inhibitors (PIs)
What Additional HIV Treatments Does Medicare Cover?
Medicare Part D 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, a Part D plan will cover these prescription drugs to help with the mental and physical effects of an HIV diagnosis and treatment. How does Medicare cover HIV treatment beyond medications? If you have Original Medicare, Part A and Part B cover much of your inpatient and outpatient care. On the other hand, Medicare Advantage (Part C) provides at least the same level of care as Parts A and B and Medicare Advantage Prescription Drug plans include 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:- Antiretroviral drugs: When an antiretroviral medication is administered by a healthcare provider in a clinical setting like a doctor’s office, Part B covers the treatment.
- 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, substitute for Original Medicare and must provide at least the same coverage as Original Medicare. Medicare Advantage Prescription Drug plans include Part D coverage. Part C plans set an out-of-pocket maximum; once you meet this threshold for the year, your insurer will pay the remainder of your costs for covered services.Medigap HIV coverage
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 can reduce your overall spending.Have questions about your Medicare coverage?
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What Is the Annual Cost of HIV Treatment?
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.
How Much Does Medicare Pay for HIV Treatments?
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
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.
Does Medicare Cover HIV Treatment if I’m Under 65?
If you’re diagnosed with HIV, Medicare can provide your coverage, even if you’re younger than 65 under certain circumstances. 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
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Sources
- Medicare Prescription Drug Benefit Manual. CMS.gov.
- HIV/AIDS Glossary. HIV.gov.
- HIV screenings. Medicare.gov.
- Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. HIV.gov.
- Medicare and HIV. KFF.
- Providing Medical Evidence for Individuals with Human Immunodeficiency Virus (HIV) Infection. SSA.gov.