Medicare covers HIV screening, diagnosis, and treatment. The primary treatment options help prevent illness and death from HIV and reduces its transmission.
A person who receives HIV treatment has out-of-pocket costs, such as copayments and deductibles.
This article provides an overview of Medicare‘s HIV benefits and describes the specific coverage and costs of each program.
Then, it offers a list of resources that help people pay Medicare costs. Lastly, it discusses HIV and its treatment.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare coverage of HIV starts with screenings. It permits one screening per year if a person is between ages 15–65, or if an individual is outside of this range but has a higher risk of HIV.
Coverage also includes doctor visits and lab tests for diagnosis. Early diagnosis and treatment are important in lengthening life expectancy.
Once a person receives a diagnosis, Medicare covers all medically necessary treatment. Because a retrovirus causes HIV, antiretroviral therapy (ART) is the main treatment. Although ART does not cure the infection, it slows its progression and makes it manageable.
Medicares Part D coverage for prescription medication extends to any other drugs a doctor may prescribe for a person with HIV. These include those for pain or poor appetite.
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Each part of Medicare offers HIV coverage in specific areas.
Original Medicare comprises Part A, hospitalization insurance, and Part B, medical insurance.
If a person with HIV requires inpatient care, Part A covers:
- hospitalization or skilled nursing facility care for a limited time
- treatments received during a hospital stay
- hospice care
- home health services, such as physical therapy
When someone with HIV needs outpatient care, Part B covers:
- doctor visits
- lab tests
- durable medical equipment (DME)
- mental health care
Medicare Advantage, also known as Medicare Part C, is the alternative to original Medicare, and it provides the same parts A and B benefits for HIV care. Most plans also include prescription drug coverage, which includes ART medications.
Special Needs Plans (SNPs) are a type of Medicare Advantage plan that tailors benefits for people with certain chronic health conditions, such as HIV.
SNPs customize drug formularies and provider choices to meet the needs of those with the infection.
Medicare Part D is prescription drug coverage, which is available to a person with original Medicare. Formularies in Part D plans include ART drugs.
Someone with a Medicare Advantage plan may not enroll in a Part D plan, but the plans often include prescription drug benefits.
Medigap plans are Medicare supplement insurance in which a person with original Medicare may enroll.
The plans provide 50–100% of parts A and B costs, including those related to HIV diagnosis and treatment.
Below are the out-of-pocket Medicare costs that a person with HIV can expect in 2021.
The Part A monthly premium is free for most people.
Other costs include:
- $1,484 deductible for each benefit period
- $0 coinsurance for days 1–60
- $371 coinsurance per day for days 61–90
- $742 coinsurance for each lifetime reserve day for days 91 and beyond
Part B costs include:
Screening involves no cost if someone meets the eligibility requirements.
Costs of Medicare Advantage plans include deductibles, copayments, coinsurance, and monthly premiums.
The costs vary among the types of plans and the companies that offer them.
As with Medicare Advantage plans, Part D costs include deductibles, copays, coinsurance, and monthly premiums.
The costs differ with the plan and the tier in which a drug falls within a formulary.
The only Medigap plan costs are the monthly premiums.
People living with HIV who have a low income may be eligible for the below programs that help pay healthcare costs.
- Medicaid is a state and federal program that is an important source of coverage for many individuals with HIV.
- Extra Help provides assistance with the prescription drug costs of Part D, offering up to $5,000 worth of help per year.
- Medicare Savings Programs help pay various out-of-pocket Medicare costs for people who meet the eligibility requirements.
In HIV, a retrovirus destroys immune system cells that fight infections and disease.
After people contract HIV, they may experience flu-like symptoms within 2–4 weeks. This is called stage 1, or the acute stage, a time in which the infection is very contagious.
The symptoms last a few days to a few weeks and include:
- sore throat
- muscle aches
- swollen lymph nodes
- night sweats
- mouth ulcers
Following the acute stage, a person with HIV enters stage 2, or the chronic stage.
During this time, someone may not have any symptoms. The rate at which this stage progresses varies, but the period may last 10 years or longer if an individual does not take HIV treatment.
Without treatment, a person with HIV may develop AIDS, which is stage 3.
People with AIDS have severe immune system damage and contract an increasing number of serious infections.
Unless someone undergoes treatment, the typical survival is 3 years. However, with current treatment options, stage 3 rarely develops.
Doctors recommend that every person with HIV start treatment, ART, as soon as possible after diagnosis.
The goal of ART is to reduce levels of the virus in the blood and bodily fluids to an undetectable level. This enables the immune system to produce more cells that fight infections.
Treatment can keep someone healthy for many years. It can also lower the risk of transmission.
Usually, ART is a combination of three or more medications. There are seven classes of ART that attack the infection in different ways. The same treatment does not affect every person with HIV in the same way, so if a combination is not working well, a doctor will change it.
The ART drugs may produce side effects, such as:
Medicare covers all medically necessary treatment for a person with HIV, which mainly involves ART.
These medications lower the infection level in the blood, an effect that helps the immune system work better. ART treatment often promotes health and extends life for many years.
A Medicare beneficiary needs to have prescription drug coverage for ART.
A person with original Medicare may receive the treatment with a Part D plan, while someone with a Medicare Advantage plan may receive this coverage with a type of plan that includes drug benefits.