ETHA and Medicaid

Two health care victories for people with HIV/AIDS

April 8, 2008

People with HIV/AIDS won two big health care victories recently. This is a notable achievement given that little legislative action is expected at the federal level due to the focus on elections.

Medicare Part D protections for people with HIV/AIDS:
On March 17, the Centers for Medicaid and Medicare Services (CMS) announced two major changes to the Medicare prescription drug benefit (Part D) program. First, no Medicare Part D plan will be able to use prior authorization on any HIV antiretroviral. Previous to the announcement, it was allowed on Fuzeon in some cases and had been considered on at least one newer antiretroviral. Prior authorization is a cost containment procedure that requires a doctor to receive permission before prescribing a drug. It can, at times, create barriers for a person trying to access a lifesaving treatment.

CMS also announced a requirement that all Part D plans add any new drugs from six “protected classes”, including all HIV antiretrovirals, within 90 days of being approved by the Food and Drug Administration Other protected classes include antidepressants, antipsychotics, anticonvulsants, anticancer, and immuno-suppressants.

These changes are the result of sustained advocacy by HIV/AIDS advocates, including Project Inform, who have been meeting with the CMS medical director on a monthly basis to discuss concerns related to Medicare Part D. To date, CMS has kept those calls focused primarily on solving problems with individual clients, despite ongoing efforts by advocates to address systemic challenges. These changes represent a major improvement to the program. It also demonstrates the importance of continued advocacy with administrative officials after a law is passed to make sure it is implemented correctly.

Medicaid expansion:
On March 13, the United States Senate voted for an amendment to the 2008 budget resolution that would create a reserve fund for an Early Treatment for HIV Act (ETHA) demonstration project. ETHA is a bill that would allow states to expand their Medicaid eligibility criteria to include low-income people with HIV, while providing an increase in federal matching funds to do so.

Currently, a person needs to be disabled (generally with an AIDS diagnosis) before being eligible for Medicaid in most states. ETHA would allow people with HIV to receive early access to care and treatment, while providing financial relief to other programs like Ryan White. This bill has been introduced in Congress the past several years, but has never come up for a vote.

An ETHA demonstration project would initially set aside a limited amount of funding (likely $500 million) for a number of states to participate. If it proved successful, it could then be expanded to cover all states. While there are many more steps towards passing ETHA or a demonstration project, this important vote puts the Senate on record as supporting the Medicaid expansion concept and moves us one step closer to making it a reality.