Annual HIV Testing Will Now Be Covered Under Medicare

Medicare beneficiaries are now eligible for HIV testing thanks to a recent policy change announced last week. Previously the Centers for Medicare & Medicaid Services (CMS) did not cover routine screenings under Medicare. The new policy includes coverage for an annual test for those who fall into various high-risk groups and pregnant women, as well as those who request testing identified risk factors.

"Today's decision marks an important milestone in the history of the Medicare program," said Secretary of Health and Human Services Kathleen Sebelius. "Beginning with expanding coverage for HIV screening, we can now work proactively as a program to help keep Medicare beneficiaries healthy and take a more active role in evaluating the evidence for preventive services."

Below is the "Decision Summary" from a CMS Decision Memo issued on December 8. The full memo, including background information, rationale, and supporting literature are available online.

Coverage Decision Memorandum for Screening for the Human Immunodeficiency Virus (HIV) Infection

The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that screening for HIV infection, which is recommended with a grade of A by the U.S. Preventive Services Task Force (USPSTF) for certain individuals, is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

Therefore CMS will cover both standard and U.S. Food and Drug Administration (FDA)-approved HIV rapid screening tests for:

1. Annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines:

• Men who have had sex with men after 1975;
• Men and women having unprotected sex with multiple [more than one] partners;
• Past or present injection drug users;
• Men and women who exchange sex for money or drugs, or have sex partners who do;
• Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users;
• Persons being treated for sexually transmitted diseases;
• Persons with a history of blood transfusion between 1978 and 1985;
• Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors; and

2. Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor.

We are deleting the following reference to non-coverage of HIV screening from the coverage manual, Section 190.14: "However, in the absence of a documented AIDS defining or HIV-associated disease, an HIV-associated sign or symptom, or documented exposure to a known HIV-infected source, the testing is considered by Medicare to be screening and thus is not covered by Medicare (for example, history of multiple blood component transfusions, exposure to blood or body fluids not resulting in consideration of therapy, history of transplant, history of illicit drug use, multiple sexual partners, same-sex encounters, prostitution, or contact with prostitutes)."

12/15/09

Sources

Centers for Medicare and Medicaid Services. Coverage Decision Memorandum for Screening for the Human Immunodeficiency Virus (HIV) Infection (CAG-00409N). December 8, 2009.

Centers for Disease Control and Prevention. HIV screening to be included in Medicare expansion. CDC HIV/Hepatitis/STD/TB Prevention News Update. December 10, 2009.