Medicare HIV Fact Sheet: Caution re January 2006

Summary: About 20 percent of people in HIV care are on Medicare, and will need to decide on a Medicare drug plan by January 2006. It will be especially important for those who are also on Medicaid to avoid interruption of treatment in early 2006, when Medicaid will no longer cover their drugs and people might not be signed up for the Medicare drug benefit in time. A revised two-page fact sheet from the Kaiser Family Foundation provides a brief overview of the Medicare program -- helpful background for understanding the additional information needed for selecting a plan.

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A two-page fact sheet on Medicare and HIV is available from the Kaiser Family Foundation, http://www.kff.org/hivaids/7171-02.cfm

Persons on Medicare (not to be confused with Medicaid) will need to make important decisions for the new prescription-drug coverage (Medicare Part D) that begins in January 2006. This fact sheet can help them get ready.

How many HIV patients will be affected? According to the best information available, cited by the fact sheet, 19% of persons in HIV care were on Medicare as of 1996. The proportion may be larger now; a separate study of Medicare billing records found that the number of people on Medicare and receiving HIV treatment increased 50% between 1997 and 2001 (the references are on the fact sheet). Most importantly, about two-thirds of the 19 percent on Medicare were also on Medicaid; this is important because for those patients on both programs ("dual eligibles"), Medicaid drug coverage will end and patients will need to get their medications through a Medicare drug plan instead. There is a risk that treatment for these patients may be interrupted in early 2006 because new arrangements are not ready in time.

The fact sheet lists some of the issues that will affect peoples' choices of a Part D drug plan for persons with HIV who have Medicare: "Formularies (the list of drugs offered) will vary by plan. Medicare drug plans must cover all antiretroviral medications but not necessarily all other medications needed by people with HIV/AIDS. Other aspects of the new law that may affect people with HIV/AIDS include: how quickly newly approved drugs will be added to formularies; whether plans will cover off-label uses for drugs (sometimes important for people with HIV/AIDS); whether dual eligibles will face temporary lapses in drug coverage as their drug benefit shifts from Medicaid to Medicare; the gap ("doughnut hole") in prescription drug coverage for many beneficiaries until their true-out-of-pocket (TrOOP) costs reach catastrophic coverage thresholds; and the uncertain impact of the Medicare drug benefit on ADAPs ... since ADAP spending for those in the doughnut hole will not count toward TrOOP."

The 19% or so of people with HIV who have or are eligible for Medicare will need to choose a plan by January 2006. While the new Part D drug benefit is voluntary (except for those also on Medicaid, whose Medicaid drug coverage will be replaced with Medicare), it will usually be strongly in peoples' interest to join, especially if they have or are likely to have large prescription-drug expenses. For many people, making a good decision in this necessary but ill-designed and complex program will be difficult.

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