Systemic and Operational Challenges Hinder Efforts to Ensure HIV Care for Medicaid Enrollees

Why OIG Did This Review

• People with HIV need ongoing recommended care to improve their health outcomes, reduce HIV-related deaths, and reduce new HIV transmissions.
• The Medicaid program plays a critical role in supporting HIV care as the largest source of insurance for Americans with HIV. Previous OIG work found that one in four Medicaid enrollees with HIV may have not received at least one service critical to HIV care in 2021.
• This report builds on OIG’s previous work by interviewing select State Medicaid agencies (States) and comprehensive, risk-based Medicaid managed care plans (Plans) to explore challenges that contribute to gaps in HIV care and potential actions that could improve their ability to ensure that all enrollees with HIV receive needed care.

What OIG Found

States and Plans reported that two systemic issues—unmet health-related social needs and provider shortages—impact enrollees’ abilities to maintain their care and limit States’ and Plans’ abilities to address resulting gaps in care.

States and Plans reported that two operational challenges—limited access to data and insufficient administrative staff—impact States’ and Plans’ efforts to monitor enrollees’ care needs and take action to connect enrollees to care.

What OIG Recommends

While the identified challenges include systemic issues that no Federal agency can solve alone, CMS has opportunities to further support State and Plan efforts to ensure that Medicaid enrollees with HIV receive needed care—thereby improving health outcomes and preventing new HIV transmissions. OIG recommends that CMS:

1. Pursue further actions to help States share knowledge with each other and coordinate internally regarding strategies to ensure needed care for Medicaid enrollees with HIV.
2. Take additional steps to help States leverage the State Data Resource Center to access and use Medicare data for dually eligible enrollees with HIV.

CMS concurred with these two recommendations.