HIV Patients Could Lose Coverage Under Medicaid Work Requirements

If applied nationwide, Medicaid work requirements could be used to target 13 percent of non-SSI, non-dual, non-elderly Medicaid adults suffering from HIV who would not be compliant with normal working requirement waiver requirements, a recent study by Kaiser Family Foundation found.

The Trump Administration released guidance on work requirements in January 2018, which allowed states to submit 1115 Medicaid demonstrations to implement community engagement incentives. 

Since then, CMS has seen 20 states’ applications for 1115 Medicaid demonstrations for work requirements. Of these, only one is currently active—Michigan’s Healthier Michigan Plan.

Previous work requirement waivers, such as Arkansas’s, have been cut off by court cases arguing that high numbers of beneficiaries could lose their Medicaid coverage due to documentation problems.

“We assessed the potential implications of these requirements for people with HIV, a population that relies heavily on Medicaid and for whom there are particularly important clinical and public health reasons for maintaining consistent access to insurance coverage and HIV care,” the study stated. “Monitoring how work requirements affect access to care and coverage for people with and at risk for HIV will be important given the potential implications on health outcomes and prevention of new infections.”

The study looked at Medical Monitoring Project (MMP) data, which is a CDC surveillance system that projects behavioral and clinical characteristics of adults with HIV nationwide. The data covered over 4,000 participants and was collected by phone or in-person interview between mid-2017 and mid-2018.

For many states that have sought a Section 1115 waiver to add community engagement to their Medicaid eligibility standards, individuals have to work 20 hours per week, or 80 hours total each month. The waivers also exempt beneficiaries with disabilities, care-giving responsibilities, and students. 

Given these conditions, the researchers found that 33 percent of individuals with HIV on Medicaid work at least 20 hours per week. Fifty percent of the HIV population in Medicaid is exempt from the work requirement due to a disability. Five percent are exempt because they have dependents or are students.

This means that 13 percent of all individuals with HIV on Medicaid would be kicked off of their Medicaid coverage if the work requirement was applied nationwide.

But they might not be the only ones to lose their Medicaid coverage. 

Nearly 9 in 10 individuals (87 percent) who are completely eligible under the work requirements, either due to their employment or because of an exemption, would have difficulty documenting or proving their compliance or exemption. While these individuals may not be in danger of permanently losing their coverage, gaps in care can result in serious consequences for individuals with HIV.

Consistent medication adherence is crucial for HIV patients. It not only prevents risk of developing a drug resistance during lapses, but also can prevent them from passing HIV to others once they achieve an undetectable viral load.

“Ensuring that people with HIV remain on coverage and engaged in care and treatment has critical clinical individual and public health benefits,” the brief confirmed.

But staying on medication requires extensive funds. In 2018, HIV treatment costs ranged from a little over $36,000 to as high as $48,000. For most, it would be difficult if not impossible to maintain their treatment without stable health insurance. Medicaid covers prescriptions, inpatient and outpatient services, and preventive care for beneficiaries with HIV.

Medicaid covers 42 percent of non-elderly patients with HIV and, with new treatments lengthening these patients’ life expectancy, Medicaid is covering them for longer than ever before. 

To scale the work requirements program nationwide could have broad implications for beneficiaries with HIV.

“The future landscape in this area is uncertain,” the researchers admitted. “If additional states move ahead with implementation and more states receive approval from the federal government, it will be important to monitor how specific policies impact access to care and coverage for people with and at risk for HIV.”