• Medicare covers doctor’s visits, medication, durable medical equipment, and more for beneficiaries living with HIV.
  • All Medicare prescription drug plans are legally required to cover HIV medications such as antiretrovirals.
  • Costs for HIV treatment under Medicare include premiums, deductibles, copayments, and coinsurance for necessary services and medications.

HIV affects millions of people across the globe. While a vaccine isn’t available just yet, early diagnosis and treatment has helped many people living with HIV lead longer, healthier lives. Medicare beneficiaries living with HIV are covered for treatment under original Medicare, Medicare Advantage, and prescription drug plans.

In this article, we’ll explore the details of Medicare coverage for the prevention, diagnosis, and treatment of 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, and limited skilled nursing facility and home health care. People with HIV who require inpatient care due to symptoms or treatment of the condition are covered 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 health care
  • end-of-life hospice care

Part B coverage

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

  • doctor and specialist appointments for prevention, diagnosis, or treatment
  • preventative HIV screenings
  • preventative 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 service 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, which 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 those with original Medicare. These plans help to cover the 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, and foreign travel emergency medical costs.

Medigap does not offer additional Medicare benefits, such as prescription drug coverage. Beneficiaries who need additional coverage should consider enrolling into Medicare Part C or Part D.

Medicare covers all medically necessary services that are used to prevent, diagnose, or treat medical conditions, such as having 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 example 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 to metabolize certain medications in the liver. Inhibiting this enzyme helps to increase the circulation of HIV drugs. These medications, cobicistat and ritonavir, 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 are used in the treatment of HIV.

There are additional HIV medications, such as fusion inhibitors and entry inhibitors, that are used to prevent HIV from entering healthy cells to replicate. If you doctor determines these are necessary for your treatment, they should be covered by Medicare prescription drug plans.

There are other medications available to help manage the physical and mental symptoms that accompany HIV treatment. These medications may help with pain, anxiety, depression, appetite, and more. Most of these medications also fall under protected categories, meaning that they will be covered under most Part D plans.

Tip

You can always contact your Part C or Part D plan provider to check if a medication you need will be covered and to find out how much it might cost.

You can always contact your Part C or Part D plan provider to check if a medication you need will be covered and to find out 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 will also cover these services, which may include:

  • HIV screenings and preventative care. Part B covers HIV screenings for individuals aged 15 to 65, as well as those who are outside of this age range but are at 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 living 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

With proper diagnosis and treatment, people with HIV can now live long, healthy lives. However, in cases where there are complications from the virus, 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, there are some alternative and long-term treatment options that might not be covered. These include:

  • Stem cell therapy. Stem cell therapy is only covered by Medicare when it is used as an FDA-approved treatment. Since stem cell therapy is not currently approved for the treatment of HIV, it will not be covered by Medicare for this use.
  • Alternative therapy. Some people living with HIV choose to use alternative therapy in addition to traditional treatments like antiretrovirals. Unfortunately, Medicare does not currently cover any alternative therapies except for acupuncture (when it is specifically used for lower back pain).
  • Long-term care. As mentioned earlier, short-term skilled nursing facility care is covered under Part A. However, Medicare does not cover long-term nursing home care or custodial care. Custodial care includes help with everyday activities like eating, bathing, and dressing. People living with HIV who require long-term, custodial care will be 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, it can cost up to $458 per month depending on the beneficiary’s work history.

In 2020, the Part A deductible is $1,408 per benefit period. This amount must be paid before Medicare will pay its share for Part A services. The Part A coinsurance for inpatient stays is $0 per day for the first 60 days, $352 per day for days 61 to 90, and $704 for each lifetime reserve day used beyond 90 days.

Part B costs

In 2020, the Part B premium is $144.60 per month, but this amount may be higher depending on the beneficiary’s income. The Part B deductible is $198 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, and copayments and coinsurance for doctor’s visits, specialist’s visits, and prescription drugs.

These costs will be different based 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 and can only cost up to $435 in 2020.

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.

HIV is a virus that attacks the immune system. Once a person has contracted HIV, the virus begins to lower their immunity by attacking the protective cells of the immune system called CD4+ cells. Early symptoms of HIV may include:

  • headache
  • fever
  • fatigue
  • sore throat
  • rash
  • body pain
  • ulcers or infections in the mouth or genitals
  • diarrhea

If HIV is left untreated, it can develop into a condition called acquired immunodeficiency syndrome (AIDS). However, over the last 20 years, the diagnosis and treatment of HIV has greatly improved. Not only are the life expectancy and quality of life getting better for people living with HIV, but current treatment options can reduce the chance of transmitting the virus to almost zero.

For people who’ve been diagnosed with HIV, antiretroviral therapy (ART) is recommended to begin immediately after diagnosis, if possible. Before ART begins, bloodwork and lab testing will be done to determine the extent of the viral infection. During ART, a team of healthcare professionals will keep a close eye on bloodwork results, symptoms, and side effects to determine how well the treatment is working.

Further resources

Having a good support system throughout treatment is important for people living with HIV. Check out Healthline’s Best HIV Blogs of 2020 for information on current HIV-related research, news, support, and more.

Healthline

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 above coverage for treatment from their doctor or by contacting Medicare directly at 800-MEDICARE (TTY: 877-486-2048) for more information.

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