Medicare HIV Coverage
April 15, 2019
Reviewed and Updated by Troy Frink,
Medicare is the government-run health insurance program for people 65 and older, and also for younger adults with qualifying disabilities. It has become a crucial source of health insurance for people who have HIV and AIDS.
The term Original Medicare refers to the federal program that started in 1965, and it describes Medicare Parts A (hospital coverage) and B (medical coverage). Medicare Part C refers to Medicare Advantage, a form of Medicare that is owned and operated by private companies, not the federal government. Medicare Advantage plans offer everything that the government Medicare program offers but can also offer additional benefits for people with HIV and AIDS.
HIV in the United States
HIV is an abbreviation for human immunodeficiency virus. The virus depletes your immune system by killing the white blood cells that fight off infection and illness. A compromised immune system means you are more likely to contract certain infections and even cancers.
More than 35 years have passed since the first documented cases of HIV in 1981. Advances in HIV prevention, care and treatment have transformed an HIV diagnosis from a death sentence to something manageable.
The population of HIV positive people in the US has grown over time to 1.1 million people. Part of this is due to improved treatment options which make for longer lifespans, but it is also due to a large number of new HIV diagnoses. According to HIV.gov, there were about 38,700 new infections in 2016 alone.
Does Medicare Cover HIV Testing?
Medicare Part B covers one annual HIV screening for those 15-65 years old. Medicare will also cover testing if you’re older than 65 or younger than 15 if you have an increased risk for HIV. Certain factors do contribute to infection susceptibility. You are at an increased risk for HIV if you have:
- Received donated blood prior to 1985: If you received a blood transfusion or blood products before 1985, it’s possible you’ve been infected with HIV because those products weren’t tested for infection. All blood products post-1985 are tested for HIV.
- A mother who was HIV positive: Pregnant women who are infected with HIV can pass the disease to their children before they give birth, during labor or through breast milk.
- Certain genes: Some people have fewer copies of a gene that fights off HIV, and some gene mutations can actually resist HIV. Genetic testing can determine whether or not you’re at an increased risk (fewer gene copies) or a decreased risk (resistant genetic mutation).
You should get tested every year, especially if you’re at risk. The first symptom of HIV is a fever accompanied with fatigue, swollen lymph nodes and sore throat. Regular testing for HIV can mean the difference between catching an infection early or letting it go untreated and progressing to AIDS. You will pay nothing if your doctor accepts your request.
Does Medicare Cover HIV Treatment?
According to the US Department of Health and Human Services, you should begin antiretroviral therapy (ART), using HIV medications to treat infection, as soon as you receive an HIV diagnosis. ART is not a cure for HIV, but the different medicines do help people live healthier, longer lives. HIV drugs prevent the virus from multiplying and therefore reducing the overall amount of HIV in the body.
When HIV replicates, sometimes the virus mutates and makes different versions of itself. Those variations can become resistant any current ART, so you must schedule regular check-ups with your doctor so he or she can reassess your treatment plan as needed.
In 2006, Medicare Part D added prescription drug benefits by offering subsidized prescriptions for otherwise costly HIV medications including approved antiretrovirals (ARVs). Part D plans are not required to cover non-ARV drugs to combat HIV-related illnesses. Certain Medicare Advantage (Part C) plans also cover FDA-approved treatments for the facial wasting (lipoatrophy) that ARVs can cause.
Medicare Special Enrollment Period and HIV
Medicare has a Special Enrollment Period (SEP) which allows people with a qualifying disability to enroll in or change coverage at any time during the year. Most people have to wait for the Initial Enrollment Period (IEP) – the three months surrounding their 65th birthday month – to enroll in coverage, or the Annual Enrollment Period (October 15 – December 7) to change coverage, but an HIV diagnosis means you qualify for a Special Enrollment Period.
A chronic, disabling condition such as HIV allows people to enroll in a Special Needs Plan (SNP). Plans for chronic conditions are called Chronic-Condition Special Needs Plans (C-SNP), and they can target one or more conditions.
Get Medicare Coverage for HIV
HIV treatment and testing have come a long way since the disease was first discovered in 1981, but it is still a serious autoimmune condition that can have dire consequences. With regular testing and preventive care, you can stay on top of your health. If you are diagnosed with HIV and qualify for the Special Enrollment Period, one of our highly qualified agents can help you find the right plan for you. Call us at 844-431-1832 or contact us here today.
