One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021

KEY TAKEAWAY

In 2021, over a quarter of Medicaid enrollees with Human Immunodeficiency Virus (HIV) did not have evidence in their claims data of receiving one or more critical services—medical visits, viral load tests, and antiretroviral therapy (ART) prescriptions. These findings demonstrate that further action is needed to ensure that enrollees are receiving appropriate HIV care. Of particular concern, over 11,000 enrollees did not have evidence of receiving any of the three services we reviewed. These services are recommended by the Department of Health and Human Services (HHS) for all people with HIV and are vital to their overall health as well as the prevention of HIV transmission within the general population.

WHY WE DID THIS STUDY

HIV is a virus that infects tens of thousands of people in the United States (U.S.) each year. While HIV affects people from all walks of life, the epidemic continues to disproportionately impact gay and bisexual men; transgender people; youth ages 13-24; and Black and Hispanic/Latino people.

People diagnosed with HIV need regular care to improve their health outcomes, reduce HIV-related deaths, and ultimately reduce new HIV transmissions. The ultimate goal of HIV care is to achieve viral suppression-meaning that the amount of HIV in the body is very low or undetectable in viral load tests. At the individual level, viral suppression allows people with HIV to stay healthy, enjoy an improved quality of life, and live longer than if they were not virally suppressed. At the population level, viral suppression prevents transmission of HIV because people with HIV who reach and maintain viral suppression have effectively no risk of passing HIV to others. Lack of viral suppression among people with HIV is often attributed to appropriate care not being initiated or not being regularly received. HHS recognizes the importance of HIV care and developed guidelines on the clinical needs of people with HIV to achieve viral suppression.

The Medicaid program plays a critical role in ensuring that people with HIV receive care that can improve their ability to achieve and maintain viral suppression. In 2018, Medicaid covered an estimated 40 percent of all nonelderly people with HIV in the U.S. People with HIV who are covered by Medicaid also tend be part of populations disproportionately impacted by HIV overall, including Black and Hispanic/Latino people.

HOW WE DID THIS STUDY

We reviewed the extent to which the Medicaid enrollees who had HIV diagnosis in their Medicaid or Medicare claims data had evidence of critical services to identify potential gaps in care in 2021. This review included both enrollees with Medicaid only and those who were enrolled in both Medicaid and Medicare (dual-eligible enrollees). We determined whether these enrollees had evidence in their Medicaid and Medicare claims data of three medical services that are critical for all people with HIV according to HHS guidelines: (1) medical visits (in-person or telehealth), (2) viral load tests, and (3) antiretroviral therapy (ART) prescriptions.

WHAT WE FOUND

Nationwide, 72,391 (or one in four) of the 265,493 Medicaid enrollees with HIV identified for this review did not have evidence of one or more critical services in 2021, with the absence of viral load tests being the most common gap in care. Further, 11,316 enrollees, or 4 percent of the 265,493 enrollees in Medicaid with HIV, did not have evidence of any of the three services in 2021, which may mean that they were at greater risk of negative health impacts and HIV transmission.

Enrollees with HIV in Medicaid only were more frequently missing evidence of critical services than dual-eligible enrollees in 2021. All States in this review had enrollees with HIV who did not have evidence of one or more critical services in 2021, but State rates varied widely.