Medicare

Medicare is a federal health insurance program that covers both seniors and people with permanent disabilities. Most individuals who are over 65 years of age are automatically entitled to Medicare if they are eligible for and receive Social Security. People under the age of 65 may be eligible for the program if they are deemed disabled due to a physical or mental impairment that prevents them from working. There is, however, a waiting period of 29 months (two years and five months) before a person who is deemed disabled becomes eligible for these benefits.

Medicare is the second largest source of federal spending for HIV/AIDS care in the United States, second only to Medicaid. It is estimated that 60,000 to 80,000 people with AIDS are beneficiaries of the program. Most Medicare beneficiaries with HIV/AIDS are under 65 and qualify as a result of their disability status (after having gone through the lengthy waiting period discussed above). For more detailed information on Medicare and HIV/AIDS, please see the Kaiser Family Foundation fact sheet [PDF] on this issue.

With the passage of the Medicare Modernization Act of 2003, Congress created a prescription drug benefit for Medicare beneficiaries. This drug benefit will take effect January 1, 2006 and is referred to as Medicare Part D. This represents the largest shift in public benefits in forty years and will have a major impact on people living with HIV/AIDS.

For many individuals, the way in which they receive their drugs will change substantially when this program goes into effect on January 1, 2006. In particular, individuals who are "dually eligible" for both Medicare and Medicaid (Medi-Cal in California) will no longer be able to receive drugs through Medi-Cal and will instead be required to obtain drug coverage through Medicare Part D. It is estimated that over 13,000 Californians living with HIV/AIDS are dual eligibles.

Unfortunately, Medicare Part D will leave many individuals worse off because they will have to meet a set of out-of-pocket expenses that are currently covered by Medi-Cal and/or the AIDS Drug Assistance Program (ADAP). Fortunately, the San Francisco AIDS Foundation, Project Inform and other advocates were successful in reducing some of these potential costs by convincing the state to allow ADAP to pay the deductibles and co-payments required of Medicare Part D beneficiaries who are dignosed with HIV. Some Part D beneficiaries, however, will have to pay premiums and ADAP will no longer be able to pay Medi-Cal share-of-cost for those who are dual eligibles.

Many of the documents and materials included below provide additional information on the implications of this new benefit and the complex ways in which it interacts with both Medi-Cal and ADAP.