Thursday, August 05, 2010


On December 8, 2009, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare would be expanding coverage for preventive services to include HIV screening. Behind this there is a story.

When Medicare was established in 1965, it was purely a program to pay for treatment, not prevention. It took a long time before preventive services began being added, a little at a time, and each one literally required an act of Congress.  For example, mammography coverage began in 1988, Pap testing in 1989. But as of 2009, 28 years into the HIV/AIDS epidemic, HIV testing was still only approved as a diagnostic measure after symptoms had already developed or following an exposure.

In 2008, Congress finally passed a bill that enabled CMS to issue rules covering additional preventive services, without going back to Congress, provided that the services were recommended by the U.S. Preventive Services Task Force. One such preventive service recommended by the Task Force was HIV screening. In spring, 2009, CMS staff were working on plans to post on the Web in September a proposal to make HIV screening the first new preventive service to be covered under this act, and were soliciting public comment. Beyond AIDS was initially unaware of this plan.

Hattis on temporary USPHS duty on a NOAA research vessel, passing an iceberg over the mid-Atlantic ridge, June 2009

However, in August 2009, Beyond AIDS President Ron Hattis, who had recently become eligible for Medicare, happened to need an HIV test as part of a physical exam for renewing his reserve status in the U.S. Public Health Service.

Hattis was shocked to get a bill for $77.00 from the laboratory, and called CMS to find out why Medicare did not cover HIV screening.  He learned that Medicare had never covered HIV screening, but that this was a timely issue being considered due to the 2008 legislation.  Hattis quickly engaged Beyond AIDS to provide testimony during the brief comment period, and to solicit the support of additional organizations.

Beyond AIDS initially feared that the Medicare proposal would leave off persons 65 and older, who are the vast majority of Medicare beneficiaries, and would not provide for more than one test a year under any circumstances. That was because the Task Force recommendation on HIV screening had been silent on the issues of age and repeat testing; and CDC's testing recommendations of September 2006 had recommended testing only for ages 13-64 and "at least" once a year for high risk individuals. When the proposal was posted in September, it fortunately did not include an age restriction, but did have a limitation of one test per year. Beyond AIDS posted testimony during the brief public comment period, and succeeded in soliciting similar testimony from the California Medical Association and the California Academy of Preventive Medicine, urging adoption of the proposal. All three organizations urged coverage of up to three tests per year, noting a number of indications for testing more than once in a year (such as pregnant women, persons with recent or ongoing exposure, and those whose Western Blot confirmatory tests are indeterminate).

Testimony was overwhelmingly positive for expanding Medicare to cover HIV testing, but Beyond AIDS and its allies were almost alone in suggesting flexibility in the one test a year limitation. In the final rule issued December 8 after consideration of all the testimony, HIV screening for all beneficiaries was covered, and additional tests for pregnant women were authorized, a partial victory for Beyond AIDS.

Hopefully, CMS will proceed with similar proposals for additional prevention services recommended by the Task Force. The Obama administration has since announced, on July 14, 2010, its intent to require other types of health insurance operating under the new health care reform plan to cover all preventive services recommended by the Task Force, at no cost to patients.

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