HIV: PRACTICAL MATTERS-FINANCING MEDICAL CARE: PUBLIC PROGRAMS FOR FINANCING HEALTH CARE-MEDICAID
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Help with financing health care is offered by both state and federal governments. One kind of help, called Medicaid, is available to those who are indigent; that is, people who are unable to support themselves. The other kind of help with finances is called Medicare. Medicare is an add-on to Social Security benefits. Therefore, if you are over sixty-five years old, or are disabled by Social Security standards, and if you are eligible for Social Security benefits, you should qualify for Medicare. Medicaid-Medicaid is a combination of state and federal programs for medical care of those who are indigent. Both state and federal governments therefore dictate the requirements for eligibility and for benefits. Medicaid is the major third-party payer for people with HIV infection. Whether you qualify as indigent, what services are available, and how much money you are eligible to receive, all vary from state to state. The definition of indigence is, in general, stringent. It ranges from an income that is 23 percent of the poverty level in South Dakota to one that is 97 percent of the poverty level in California; in thirty-four states, the definition is 50 percent of the poverty level. In other words, if the poverty level is around $7,000 per year for one person, then most states will find you eligible for Medicaid if your income is $3,500 per year or less. Some states have a definition of indigence with a higher income level for people with AIDS; that is, people with AIDS can qualify for financial help from public funds and still be relatively able to support themselves. Some states also have definitions of indigence that are substantially higher for women who are pregnant and for children. In defining indigence, Medicaid also considers resources you have other than income. To be considered indigent, you may have liquid assets (for instance, a savings account), a car, a house, or other property only if their values are below a certain level. What that level is differs in different states. Medicaid pays for most medical necessities, but pays relatively little for each one, especially for physicians’ fees. It pays for inpatient services, outpatient services, and skilled nursing home services. In some states, Medicaid also pays for home health care, private nursing, and drugs. Some states pay for as few as fourteen days of hospital care; some states have no limit. Some have special programs for people with HIV infection. Professional fees such as physicians’ bills are usually reimbursed at only about 20 percent of the physicians’ customary charges. As a result, unfortunately, many physicians do not accept patients who are on Medicaid. Home care, hospital care, and chronic care are also reimbursed at low rates, and some facilities will reject Medicaid patients on similar grounds. Medicaid will pay for all drugs, but often restricts payment to drugs that the FDA has approved and sometimes pays only for conditions the drug is specifically approved for. This means that if a clinical trial shows a drug is useful, Medicaid will not pay for the drug until the FDA has approved it. If the FDA has approved the drug but has not approved it specifically for a certain condition, Medicaid may deny payment until the drug is approved for this condition.*207\191\2*
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