Does Medicare Cover Treatment for HIV?

Original Medicare, Medicare Advantage, and Medicare Part D all offer different coverage options for HIV treatment.

Part A coverage

Medicare Part A covers hospital care, hospice care, limited skilled nursing facility care, and home healthcare.

People with HIV who need inpatient care due to symptoms or treatment have coverage for:

• short-term inpatient hospital stays
• medications or therapies needed during the hospital stay
• short-term inpatient care at a skilled nursing facility
• limited home healthcare
• end-of-life hospice care

Part B coverage

Medicare Part B covers preventive, diagnostic, and outpatient treatment services. People with HIV who require testing, medications, and other services for the condition are covered for:

• doctors’ and specialists’ appointments for prevention, diagnosis, or treatment
• preventive HIV screenings
• preventive HIV vaccinations (when developed)
• lab testing, imaging, and other diagnostic testing
• medications administered at an outpatient facility by a healthcare professional
• mental health counseling during treatment

Part C coverage

Medicare Part C, also known as Medicare Advantage, is a private insurance option that’s used in place of Original Medicare (parts A and B).

Part C must cover everything you’d get with Original Medicare, including all hospital and medical services necessary to treat HIV.

Most Medicare Advantage plans also offer additional coverage for prescription drugs, such as those used to treat HIV.

In some cases, a Medicare Advantage Special Needs Plan (SNP) can offer additional benefits for people with chronic health conditions.

All SNPs offer prescription drug coverage, condition-specific specialists, and other medical items and services that may benefit beneficiaries living with HIV.

Part D coverage

Medicare Part D helps cover prescription drugs that are taken at home, such as those needed for HIV prevention and treatment.

Part D plan costs and coverage vary depending on the plan’s drug formulary. A formulary is a tiered system that breaks each drug into categories based on type and price.

However, no matter the formulary, all Medicare prescription drug plans are required to cover certain protected drug classes, including those used for treating HIV.

Medigap coverage

Medigap is added coverage for people with Original Medicare. These plans help cover costs associated with coverage. All Medigap plans cover Part A coinsurance and copayment costs, Part B coinsurance and copayment costs, and blood transfusions.

Some plans also cover:

• Part A and Part B deductibles
• nursing facility costs
• excess charges
• foreign travel emergency medical costs

Medigap does not offer additional Medicare benefits, such as prescription drug coverage or services that are not covered by Medicare. Beneficiaries who need additional coverage should consider enrolling in Medicare Part C or Part D.

Medicare covers all medically necessary services that are used to prevent, diagnose, or treat medical conditions, such as HIV.

Medications

Antiretrovirals are the primary class of medications used to treat HIV. All Medicare prescription drug plans cover antiretrovirals when they are used in the treatment of HIV.

These antiretroviral drugs may include:

• Integrase inhibitors: These drugs inhibit HIV from producing an enzyme called integrase, which it uses to duplicate and spread. Dolutegravir and raltegravir are examples of integrase inhibitors.
• Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs): These drugs stop HIV from copying itself by inhibiting an enzyme called reverse transcriptase. Abacavir, lamivudine, and zidovudine are examples of NRTIs.
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs): These drugs are similar to NRTIs in that they prevent HIV from copying itself by inhibiting reverse transcriptase. Efavirenz and nevirapine are examples of NNRTIs.
• Cytochrome P4503A (CYP3A) inhibitors: These drugs inhibit an enzyme called cytochrome P4503A, which helps metabolize certain medications in the liver and increases the circulation of HIV drugs. Cobicistat and ritonavir are examples. They are generally only used in combination with other antiretrovirals.
• Protease inhibitors (PIs): These drugs prevent HIV from replicating by binding to protease, an enzyme the virus uses to replicate. Darunavir and ritonavir are examples of PIs that help treat HIV.

Additional HIV medications, such as fusion inhibitors and entry inhibitors, may help prevent HIV from entering healthy cells to replicate. If your doctor determines these are necessary for your treatment, Medicare prescription drug plans will likely cover them.

Other medications can help manage the physical and mental symptoms that accompany HIV treatment, including:

• pain
• anxiety
• depression
• appetite

Most of these medications also fall under protected categories, meaning they will be covered under most Part D plans.

You can always contact your Part C or Part D plan provider to check whether a medication you need is covered and how much it might cost.

Services

Services used for the prevention, diagnosis, and treatment of HIV are generally covered under either Medicare Part A or Part B. Medicare Advantage also covers these services.

Services may include:

• HIV screenings and preventive care: Part B covers HIV screenings for individuals 15 to 65 years old as well as those outside this age range but who have an increased risk. Screening is covered once per year for qualifying beneficiaries and up to three times per year for beneficiaries who are pregnant.
• Limited skilled nursing care: Part A covers short-term skilled nursing care either at an inpatient facility or in your home. To qualify, you must require daily skilled care. While most people living with HIV can have a high quality of life with treatment, others may require skilled nursing care from time to time.
• Mental health care: According to the National Institute of Mental Health, people with HIV are more likely to develop mental health conditions. Mental health services, such as those offered by therapists or psychiatrists, are covered under all Medicare Part B plans.

Durable medical equipment

If you have complications from HIV, durable medical equipment may be necessary during treatment. This equipment is covered under Medicare Part B and may include:

• canes and crutches
• hospital beds
• infusion supplies
• nebulizers
• oxygen equipment
• walkers, wheelchairs, and scooters

While almost all treatments approved for HIV are covered by Medicare, some alternative and long-term treatment options may not be covered. These include:

• Stem cell therapy: Medicare covers stem cell therapy only when used as a Food and Drug Administration (FDA) approved treatment. Since it’s not currently approved for the treatment of HIV, it will not be covered for this use.
• Alternative therapy: Some people living with HIV choose to use alternative therapy in addition to traditional treatments like antiretrovirals. Medicare does not currently cover any alternative therapies except for acupuncture (when it is specifically used for lower back pain).
• Long-term care: Medicare does not cover long-term nursing home care or custodial care, which includes help with everyday activities like eating, bathing, and dressing. People living with HIV who require long-term custodial care are responsible for 100% of these costs.

Medicare costs for HIV treatment depend on the type of Medicare coverage you have as well as the services and medications that are needed for your treatment.

Part A costs

The Part A premium is generally $0 per month for most beneficiaries. However, depending on the beneficiary’s work history, it can cost up to $505 per month.

In 2024, the Part A deductible is $1,632 per benefit period. This amount must be paid before Medicare will pay its share for Part A services.

For inpatient stays, Part A coinsurance is as follows:

• First 60 days: $0 per day
• Days 61 to 90: $408 per day
• For each lifetime reserve day used beyond 90 days: $816

Part B costs

In 2024, the Part B premium is $174.70 per month, but this amount may be higher depending on the beneficiary’s income.

The Part B deductible is $240 per calendar year, and this must also be paid before Medicare pays for Part B services.

The Part B coinsurance you’ll pay for Medicare-approved services, therapy, or equipment is 20% of the Medicare-approved amount.

Part C costs

Medicare Part C costs include all Part A and Part B costs plus any additional plan costs. Plan costs can include:

• a monthly premium
• prescription drug premium and deductible
• copayments and coinsurance for doctors’ visits, specialists’ visits, and prescription drugs

These costs will vary depending on the company supplying coverage, the plan you choose, and even the area where you live.

Part D costs

As with Part C, your Part D prescription drug plan premium will depend on the type of plan you choose. However, the deductible is capped by Medicare: It can only cost up to $545 in 2024.

Copayments and coinsurance for prescription drugs also vary depending on the types of medications needed and the tier they fall into within the plan’s formulary.

You can check your plan’s formulary in the documents you were provided, on your plan’s website, or by calling the insurance company directly.

Both Original Medicare and Medicare Advantage offer services for the prevention, diagnosis, and treatment of HIV.

However, the majority of Medicare coverage for HIV treatment, specifically antiretrovirals, comes with Medicare’s prescription drug plan coverage.

Costs for HIV treatment under Medicare include premiums and deductibles as well as copayments and coinsurance for services and medications.

Medicare beneficiaries living with HIV can learn more about coverage for treatment from their doctor or by contacting Medicare directly at 800-MEDICARE (TTY: 877-486-2048) for more information.