DEPARTMENT OF HEALTH & HUMAN SERVICES                                                                            
 
Joint HHS, CMCS, HRSA, and CDC Informational Bulletin 
 
Opportunities to Improve HIV Prevention and Care Delivery 
to Medicaid and CHIP Beneficiaries 
December 1, 2016 
 
Purpose  
In July 2015, the White House released the National HIV/AIDS Strategy (NHAS) for the United 
States: Updated to 20201. The Strategy articulates four goals: 1) reduce new HIV infections; 2) 
increase access to care and improve health outcomes for people living with HIV (PLWH); 3) 
reduce HIV-related health disparities and health inequities; and 4) achieve a more coordinated 
national response to the HIV epidemic.  Medicaid is the largest payer of HIV care in the United 
States2, and the advent of the Affordable Care Act (ACA) has further expanded Medicaid access 
to many individuals living with, or at high risk for acquiring, HIV. States will, therefore, 
continue to play an instrumental role in achieving national goals, as outlined in the NHAS.  
This Informational Bulletin (IB) informs state Medicaid agencies about important advances in 
HIV prevention, care and treatment that have occurred in the five years since the Center for 
Medicaid and CHIP Services (CMCS) outlined opportunities available to provide Medicaid 
coverage to individuals living with HIV in a letter to State Medicaid Directors (SMD) titled 
Coverage and Service Design Opportunities for Individuals Living with HIV, which can be 
found at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/11-005.pdf.  
Additionally, this IB highlights opportunities available to state Medicaid programs to drive 
improvements in the accessibility, quality, cost, and population-level impact of HIV prevention 
and care services available to Medicaid beneficiaries. 
Background 
                                                           
1 National HIV/AIDS Strategy for the United States: Updated to 2020. https://www.aids.gov/federal-
resources/national-hiv-aids-strategy/nhas-update.pdf.  Accessed June 30, 2016. 
2 Centers for Disease Control and Prevention. Behavioral and Clinical Characteristics of Persons Receiving Medical 
Care for HIV InfectionMedical Monitoring Project, United States, 2013 Cycle (June 2013May 2014). HIV 
Surveillance Special Report 16.  http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-hssr-mmp-
2013.pdf. Accessed June 30, 2016.  According to data from the Medical Monitoring Project (MMP), a CDC 
surveillance system that collects locally and nationally representative behavioral and medical record data from 
people living with HIV, 42% of PLWH who were receiving HIV medical care in 2013 were insured through 
Medicaid.    Informational Bulletin  Page 2   
 
The Centers for Disease Control and Prevention (CDC) estimates that approximately 1.24 
million persons in the United States are living with HIV infection, and about 13% of those 
individuals are unaware of their infection3.  In the United States, the HIV epidemic is more 
prevalent in certain geographic areas and populations4,5.  Nearly half of people living with HIV 
(PLWH) who are currently receiving care for their infections have incomes at or below the 
federal poverty level (< 100% FPL) and so are potentially eligible for Medicaid or Child Health 
Insurance Program (CHIP) coverage6. Substantial population and geographic disparities 
characterize HIV-related health outcomes as well.  In its most recent State HIV Prevention 
Progress Report for 2010 - 2013, CDC found substantial variance among states with respect to a 
range of measures, including death rates among persons diagnosed with HIV and the percentages 
of people living with HIV who were aware of their infections and successfully linked to, and 
subsequently retained care7.   
The science of HIV prevention and care has advanced rapidly over the past 5 years8. A series of 
landmark studies, including HIV Prevention Trial Network (HPTN) 052, Strategic Timing of 
Antiretroviral Treatment (START),  and TEMPRANO ANRS, have conclusively demonstrated 
that early treatment offers important preventive and clinical benefits, including gains in life 
expectancy, better quality of life, longer delay in average time until onset of AIDS, and fewer 
transmissions9,10,11,12.    To reduce the morbidity and mortality associated with HIV infection, the 
                                                           
3Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by 
using HIV surveillance dataUnited States and 6 dependent areas, 2014. HIV Surveillance Supplemental Report 
2016; 21(No. 4). http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-
vol-21-4.pdf. Accessed August 1, 2016. 
4 Centers for Disease Control and Prevention. HIV Surveillance Report, 2014; vol. 26. 
http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-us.pdf. Accessed June 30, 2016.  
See also http://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-surveillance-genepi.pdf for graphical representations 
of these disparities. 
5 NHAS: Updated to 2020 (see footnote 1) 
6 CDC, Medical Monitoring Project, United States, 2013 Cycle (June 2013May 2014) (see footnote 2) 
7 Centers for Disease Control and Prevention. State HIV Prevention Progress Report, 20102013. 
http://www.cdc.gov/hiv/pdf/policies/progressreports/cdc-hiv-stateprogressreport.pdf.  Accessed June 30, 2016. 
8 Due to space constraints, this information bulletin only highlights a few key developments within the broader suite 
of changes that have occurred between 2010 and 2015.  For a more complete description of important scientific 
advances in the arenas of HIV prevention and care, see https://www.aids.gov/federal-resources/national-hiv-aids-
strategy/nhas-update-5-things.pdf. 
9 Farnham PG, Gopalappa C, Sansom SL et al. Updates of lifetime costs of care and quality-of-life estimates for 
HIV-infected persons in the United States: late versus early diagnosis and entry into care. Journal of Acquired 
Immune Deficiency Syndrome. 2013; 64(2): 183-9.  
10 Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N et al. Antiretroviral Therapy 
for the Prevention of HIV-1 Transmission.  New England Journal of Medicine 2016; published online July 18, 2016; 
DOI: 10.1056/NEJMoa1600693 
11 The INSIGHT START Study Group. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. 
The New England Journal of Medicine. 2015; 373 (9): 795-807. 
12 TEMPRANO ANRS 12136 Study Group. A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in 
Africa.  New England Journal of Medicine 2015; 373 (9): 808-22. 
    Informational Bulletin  Page 3   
 
Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents13 
strongly recommend antiretroviral treatment (ART) for all HIV-infected individuals, regardless 
of CD4 T lymphocyte cell count. 
Some antiretrovirals have also been shown to reduce HIV acquisition risk among people who are 
uninfected.  Evidence from several large, randomized controlled trials indicates that daily oral 
pre-exposure prophylaxis (PrEP) with an FDA-approved, HIV prescription medicine can reduce 
HIV acquisition risk by more than 90% when taken as prescribed14. Recent PrEP demonstration 
studies and programs have also shown that maintaining the requisite high levels of adherence is 
possible and results in high levels of effectiveness under real world conditions15,16.  As a 
consequence, the U.S. Public Health Service (USPHS) recommends PrEP as one prevention 
option for people who are HIV-negative and at substantial risk for HIV17. 
Advances in HIV surveillance systems and methods have improved federal, state, and local 
efforts to evaluate and improve outcomes along the HIV care continuum. The HIV care 
continuumsometimes referred to as the HIV treatment cascadeis a model that outlines the 
stages of HIV medical care that PLWH go through from initial diagnosis to achieving the goal of 
viral suppression, showing the proportion of PLWH who are engaged at each stage.  States that 
have successfully implemented requirements that laboratories report all CD4 values and viral 
load (VL) test results to HIV surveillance programs are able to calculate the full HIV care 
continuum for their residents18.  Data from these jurisdictions, which are also used to track 
progress towards national objectives, indicate that only 55% of persons diagnosed and living 
with HIV were virally suppressed at the end of 201319. 
                                                           
13Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in 
HIV-1-infected adults and adolescents. Department of Health and Human Services. 
https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0. Accessed June 30, 2016. 
14 U.S. Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States
2014 Clinical Practice Guideline. May 2014. http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf.  Accessed June 
30, 2016.  
15Liu AY, Cohen SE, Vittinghoff E, Anderson PL, Doblecki-Lewis S, Bacon O et al. Preexposure Prophylaxis for 
HIV Infection Integrated With Municipal- and Community-Based Sexual Health Services. JAMA Intern Med. 2016; 
176 (1): 75-84. 
16Grant RM, Anderson PL, McMahan V, Liu A, Amico KR, Mehrotra M et al. Uptake of pre-exposure prophylaxis, 
sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. The 
Lancet Infectious Diseases. 2014; 14 (9): 820-9. 
17 The guidelines (see footnote 14) and their associated providers supplement (available at 
http://www.cdc.gov/hiv/pdf/PrEPProviderSupplement2014.pdf) provide detailed algorithms that can be used to 
assess sexual and/or injection drug transmission risks. 
18 Details about state specific progress toward successfully implementing such reporting requirements is available 
from CDCs 2015 Prevention Status Reports.  Available at: http://wwwn.cdc.gov/psr/. Accessed June 30, 2016. 
19 Monitoring selected national HIV prevention and care objectives by using HIV surveillance dataUnited States 
and 6 dependent areas2014 (see footnote 3)   
    Informational Bulletin  Page 4   
 
The aforementioned scientific advances, as well as important shifts in health policy and delivery 
system landscapes resulting from the Affordable Care Acts passage in 201020, present 
opportunities for states to  improve HIV prevention and care outcomes among their residents.  
Through their design and implementation of benefits and programs, state Medicaid programs are 
instrumental to realizing these opportunities. 
In 2013, the Health Resources and Services Administration (HRSA) and the Center for Medicaid 
and CHIP Services (CMCS) jointly released an Informational Bulletin regarding coordination 
between Medicaid and Ryan White HIV/AIDS Programs.  HHS noted that Ryan White Programs 
were the payer of last resort and could be used to wrap additional benefits not covered by 
Medicaid. Additionally, CMS and HRSA announced a series of webinars for states, providers and 
stakeholders conducted throughout the second half of 2013. The Informational Bulletin, dated 
May 1, 2013, may be found at https://www.medicaid.gov/federal-policy-guidance/federal-policy-
guidance.html. 
HIV Testing and Diagnosis  
HIV testing functions as an entry point to prevention and care services for Medicaid 
beneficiaries.  Those who test negative but are at increased risk for infection can be linked to 
appropriate prevention services (including PrEP).  Those who test positive for HIV can be linked 
to HIV medical care and begin ART.  While early diagnosis and treatment may be associated 
with greater aggregate costs for HIV care over a 30+ year time horizon21, annual and 5-year 
average costs for HIV care are typically much lower for persons who are diagnosed earlier in the 
course of their infections22,23.  For example, in a recent analysis, Fleishman et al. found that the 
average annual Medicaid payment for medical and support services was $65,96724 per 
beneficiary for those whose CD4 count fell below 200 cell/mm3 at the start of the measurement 
year. By contrast, the commensurate average annual Medicaid payment was $36,377 for persons 
whose CD4 count was greater than or equal to 500 cells/mm3a nearly 50% reduction 25. 
                                                           
20 An overview of how key provisions of the ACA affect the accessibility, availability, affordability, and quality of 
HIV prevention and care services is available at https://www.aids.gov/federal-resources/policies/health-care-reform/. 
Accessed June 30, 2016. 
21 In part because the lifetime in question is substantially longer and in part because the number of years on 
treatment (even in the absence of life expectancy gains) is greater. 
22 Krentz HB, Gill J. Despite CD4 cell count rebound the higher initial costs of medical care for HIV-infected 
patients persist 5 years after presentation with CD4 cell counts less than 350 l. AIDS. 2010; 24 (17): 2750-2753.  
23 Gebo KA, Fleishman JA, Conviser R, et al. Contemporary Costs of HIV Healthcare in the HAART 
Era. AIDS. 2010; 24 (17): 2705-2715. 
24 The dollar values presented in this paper are standardized to US 2010 dollars. 
25 Fleishman JA, Monroe AK, Voss CC, Moore RD, Gebo KA. Expenditures for Persons Living With HIV Enrolled 
in Medicaid, 2006-2010. J Acquir Immune Defic Syndr. 2016; 72 (4): 408-15.   
    Informational Bulletin  Page 5   
 
Additionally, early diagnosis and treatment of HIV infection improves both the length and 
quality of life and substantially reduces the number of new infections transmitted.26 
 
 
U.S. Preventive Service Task Force Screening Recommendations 
The U.S. Preventive Services Task Force (USPSTF) recommends27 that all persons between the 
ages of 15 and 65 be screened at least once for HIV infection, regardless of risk.  Further, the 
USPSTF recommends repeat screening for individuals at increased risk28 for infection (including 
at-risk individuals who are younger than 15 or over the age of 65).  For individuals at very high 
risk of new HIV infections, who include men who have sex with men (MSM) and persons who 
inject drugs, the USPSTF suggests that an appropriate rescreening interval would be one year.  
Finally, the USPSTF recommends that all pregnant women be screened for HIV, including those 
who present in labor who are untested and whose HIV status is unknown29. 
State Medicaid programs are encouraged to ensure the availability, accessibility, and 
affordability of HIV testing services for beneficiaries living with, or at risk of acquiring HIV.  
Coverage design elements that can help accomplish this include removing cost-sharing barriers, 
as well as ensuring the availability of services from providers best suited to reach, and be 
reached by, target populations. 
To this aim, prior to the ACA and the expansion of Medicaid to the new adult group, CMS 
released guidance in May 2000 to assist states to develop section 1115 demonstration proposals 
to expand Medicaid coverage to provide early treatment to PLWH30.  Two states utilized the 
                                                           
26 Farnham, Paul G. PhD *; Gopalappa, Chaitra PhD *; Sansom, Stephanie L. PhD *; Hutchinson, Angela B. PhD *; 
Brooks, John T. MD *; Weidle, Paul J. PharmD *; Marconi, Vincent C. MD +,++,[S]; Rimland, David MD +,++  
Updates of Lifetime Costs of Care and Quality-of-Life Estimates for HIV-Infected Persons in the United States: Late 
Versus Early Diagnosis and Entry Into Care.  JAIDS Journal of Acquired Immune Deficiency Syndromes. 64(2):183-
189, October 1, 2013. 
27 The USPSTF has assigned an A grade to its recommendation, indicating that there is a high certainty that the 
net benefit is substantial. 
28 Patient populations that would more likely benefit from more frequent testing include those who are known to be 
at higher risk for HIV infection (e.g., Men who have Sex with Men, active injection drug users, and persons recently 
diagnosed with a sexually transmitted disease, or STD), those who are actively engaged in risky behaviors (e.g., 
unprotected vaginal or anal intercourse), and those who live or receive medical care in a high-prevalence setting 
(e.g., TB or STD clinics).   
29 U.S. Preventive Services Task Force. Final Recommendation Statement: Human Immunodeficiency Virus (HIV) 
Infection: Screening. May 2015. 
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-
virus-hiv-infection-screening. Accessed June 30, 2016. 
30 See guidance issued May 31, 2000 to State Medicaid Directors titled "1115 Waivers Proposal Guidelines that 
Target Individuals with HIV/AIDS," which can be found at https://www.medicaid.gov/Federal-Policy-
Guidance/downloads/smd053100b.pdf.  Accessed October 18, 2016 
    Informational Bulletin  Page 6   
 
1115 option to specifically target the expansion of coverage to PLWH while several other states 
included coverage of PLWH as part of a larger comprehensive 1115 demonstration31.  In June 
2011, CMS released additional guidance expanding opportunities to assist states in increasing 
access to care for PLWH through other mechanisms such as health homes, section 1915(c) home 
and community based services waivers, and section 1915(i) or 1915(k) Medicaid State Plan 
options in addition to section 1115 authority32.  Through Medicaid state plan authority states 
have historically provided coverage for a variety of services for PLWH such as physician, 
hospital, other licensed practitioner, pharmacy, and rehabilitation services. 
In the Health Insurance Marketplace and for the Medicaid expansion population, the Affordable 
Care Act (ACA) requires the coverage of Essential Health Benefits (EHB), which includes 
covering without cost sharing 1) preventive services that have in effect an A or B rating 
from the USPSTF, including HIV testing for all persons between the ages of 15 and 65; 2) 
immunizations recommended by the Advisory Committee on Immunization Practices (ACIP); 
and 3) guidelines for preventive care and screenings for women, infants, and children recognized 
by the Health Resources and Services Administration (HRSA)33.  In 42 CFR 440(c) and 45 CFR 
156, CMS further clarified that these coverage requirements are included in the definition of 
EHB.  Therefore, they are applicable to Qualified Health Plans (QHPs) sold through the Health 
Insurance Marketplace and Alternative Benefit Plans (ABPs) offered to Medicaid Expansion 
populations.   
Authorized through section 4106 of the ACA, as part of their standard Medicaid benefit package 
for adults who are 21 and over, states that choose to cover without cost sharing all USPSTF A 
and B services and the ACIP recommended immunizations and their administration are eligible 
to receive a one percentage point Federal medical assistance percentage (FMAP) increase for 
these services34. To date, 12 states35 have applied for and received such an increase.  
State Medicaid programs are also encouraged to be creative in exploring potentially more 
efficient options for delivering HIV testing and other critical preventive services that are 
                                                           
31 Two states implemented 1115s targeted to only PLWH: 1) Washington, D.C. was approved in 2001 and operated 
until January 2011 when coverage transitioned to the State Plan option for the new adult group as authorized by 
ACA; and 2) Maine was approved in 2000 and continues to serve PLWH under a targeted 1115 demonstration as of 
the date of this release.  The following states provide coverage to PLWH as part of a statewide comprehensive 1115 
demonstration: CA, FL, MA, NY, OR, and RI.  See Medicaid.gov for more information on these demonstration 
programs.   
32 See guidance issued June 6, 2011 to State Medicaid Directors titled "Coverage and Service Design Opportunities 
for Individuals Living with HIV (#11-005)," which can be found at https://www.medicaid.gov/Federal-Policy-
Guidance/downloads/11-005.pdf.  Accessed October 18, 2016 
33 Coverage of Certain Preventive Services Under the Affordable Care Act, 80 FR 41317 (July 14, 2015) 
34 See In guidance issued in 2013 to State Medicaid Directors titled Affordable Care Act Section 4106 (Preventive 
Services), which can be found at https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-
002.pdf. Accessed September 20, 2016 
35 CA, CO, DE, HI, KY, NH, NJ, NV, NY, OH, WA and WI 
    Informational Bulletin  Page 7   
 
recommended by the USPSTF to beneficiaries. As discussed in previous guidance36, CMS 
revised its regulatory definition of preventive services at 42 CFR 440.130(c) to be consistent 
with the statutory provision at section 1905(a) (13) of the Social Security Act (the Act) that 
governs preventive services. Specifically, section 1905(a) (13) indicates that services must be 
recommended by a physician or other licensed practitioner of the healing arts within the scope 
of their practice under State law. Accordingly, at their option, states may submit a state plan 
amendment (SPA) in which they propose to cover preventive services37 that are recommended 
by physicians or other licensed practitioners, but provided by unlicensed practitioners who meet 
the qualifications established by the state, provided the rest of the requirements for the 
preventive services benefit are met.  States may leverage this change to expand access to HIV 
testing services among Fee-For-Service (FFS) Medicaid and CHIP beneficiaries by, for example, 
extending coverage to HIV testing conducted in community settings by Disease Intervention 
Specialists (DIS) or community health workers (CHWs).  To the extent allowed by applicable 
Federal and state regulations, states that contract with Managed Care Organizations (MCOs) to 
deliver health care services to Medicaid and CHIP beneficiaries may consider adding contractual 
provisions that similarly allow or incentivize coverage for HIV testing services provided by DIS, 
CHWs, or other qualified non-licensed, community-based practitioners.  
Pre-Exposure Prophylaxis (PrEP) for HIV Prevention 
Pre-exposure prophylaxis, or PrEP, refers to a new prevention method in which people take a 
daily pill containing an antiretroviral medication emtricitabine and tenofovir disoproxil 
(Truvada) that has been shown to safely and effectively reduce the risk of HIV acquisition in a 
variety of populations38.  The FDA has approved the combination of emtricitabine and tenofovir 
disoproxil for a PrEP indication among adults who are at high risk for acquiring HIV.  However, 
while PrEP is a highly effective, safe intervention for HIV prevention, it is also an under-utilized 
one.   
In 2014, the U.S. Public Health Service (USPHS) released Preexposure Prophylaxis for HIV 
Prevention in the United States - 2014: A Clinical Practice Guideline, the first comprehensive 
clinical practice guidelines for PrEP39.  Among other things, these guidelines 
  Provide criteria for determining a persons HIV risk and indications for PrEP use; 
                                                           
36 Update on Preventive Services Initiatives. Center for Medicaid and CHIP Services, CMS, November 2013.  
https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-11-27-2013-Prevention.pdf.  Accessed June 30, 
2016. 
37 Details about which preventive services do and do not qualify are available in 42 CFR 440.130(c) and the State 
Medicaid Manual Section (SMM) 4385 
38 USPHS, Preexposure Prophylaxis for the Prevention of HIV Infection in the United States2014 Clinical 
Practice Guideline.  See especially the evidence summaries in Tables 2-6 (see footnote 14) 
39 Ibid. 
    Informational Bulletin  Page 8   
 
  Recommend regular clinical follow-up that includes periodic rescreening for HIV 
infection and other sexually transmitted diseases, as well as assessment for side effects, 
adherence, and HIV acquisition risk behaviors;    
  Underscore that PrEP is not the only option for reducing HIV risk, and its use does not 
obviate the importance of, or need for, other risk-reduction approaches (e.g., using 
condoms); and 
  Clarify that PrEP is not intended or expected to require a lifelong commitmentpeople 
may discontinue PrEP for a variety of reasons, including changes in their life situations 
that substantially reduce or eliminate their risk for acquiring HIV.  
 
States that elect to provide prescription drug benefits must comply with the requirements of 
section 1927 of the Act, which in paragraph (d) provides parameters for limitations on coverage 
of outpatient drugs of manufacturers that have in effect rebate agreements. 
States have the discretion to establish certain limitations, prior authorization processes or 
preferred drug lists, on the coverage of PrEP to ensure appropriate utilization when medically 
necessary; however, we encourage states to take steps to ensure that PrEP is available consistent 
with USPHS recommendations.  For example, neither Colorado nor Washington State subject 
emtricitabine/ tenofovir to prior authorization processes when it is prescribed for HIV treatment 
or HIV PrEP. Because regular HIV and STD tests are recommended for persons who initiate 
PrEP, Washingtons Medicaid program also facilitates access to these testing services by 
covering their receipt on a quarterly basis and in a range of settings that may be more convenient 
or comfortable for beneficiaries (e.g., family planning clinics, local health departments, or 
primary care settings). States should ensure that beneficiaries being initiated on PrEP are 
educated about and provided with sufficient supportive care to ensure adherence to regimens. 
Additional strategies states may consider to ensure that utilization management techniques are 
not designed or implemented in ways that amount to denial of access to PrEP among persons for 
whom it is indicated include 1) provider education, 2) development of clear policies and 
procedures for assessing and making determinations about indications for PrEP, and 3) careful 
review and monitoring of Medicaid FFS and managed care benefits and coverage. 
Linkage to and Retention in Care for People Living with HIV 
For PLWH to achieve and maintain virologic suppression, they must be linked to and remain 
engaged in HIV care and treatment.  National and state-specific estimates of the HIV care 
continuum indicate that significant numbers of PLWH do not enter HIV care following their 
diagnosis and even greater numbers do not remain in care.  In 2013, only slightly more than half 
of persons who had been diagnosed with HIV were successfully retained in care; state-specific 
averages (from the 33 jurisdictions with complete CD4 and VL reporting) ranged from a low of 
30% to a high of 68%--which is substantially lower than the national goal that 90% of persons 
    Informational Bulletin  Page 9   
 
living with diagnosed HIV infections be retained in HIV care40,41. Linkage to and retention in 
HIV care and treatment are crucial to achieving sustained viral suppression, which can result in 
reduced transmission to others and improved clinical outcomes for persons living with HIV 
infection. 
PLWH often face a variety of medical and social challenges that impede their access to, retention 
in, and adherence to HIV care and treatment.  These include increased risk for, and prevalence 
of, comorbidities such as depression and substance use disorders42. They also include broader 
social determinants of health, including poverty, unemployment, homelessness, and inadequate 
access to transportation43.  Comprehensive, coordinated, patient-centered delivery systems and 
models of care thus offer important means through which states can improve outcomes among 
their Medicaid and CHIP beneficiaries living with HIV.  
State Innovations to Support Engagement in HIV Care 
The Medicaid Health Home State Plan Option, as authorized under the Affordable Care Act 
(Section 2703), can be a particularly effective model for coordinating and delivering the medical 
care, behavioral health care, and community-based social services and supports PLWH need to 
successfully navigate the HIV care continuum and achieve viral suppression.  Many of the 
services that define the Health Home modelincluding comprehensive care management, care 
coordination and health promotion, individual and family support, and referral to community and 
social support servicesare recommended strategies for improving engagement in care among 
PLWH44,45.  These mandated core services of the Medicaid health home are also core elements of 
the comprehensive system of care developed and supported through the Ryan White HIV/AIDS 
                                                           
40 See especially Table 4b from Monitoring selected national HIV prevention and care objectives by using HIV 
surveillance dataUnited States and 6 dependent areas2014 (see footnote 3) 
41 NHAS: Updated to 2020 (see footnote 1)  
42 CDC, Medical Monitoring Project, United States, 2013 Cycle (June 2013May 2014) (see footnote 2) 
43 Ibid.   
44 Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institutes of 
Health, American Academy of HIV Medicine, Association of Nurses in AIDS Care, International Association of 
Providers of AIDS Care, the National Minority AIDS Council, and Urban Coalition for HIV/AIDS Prevention 
Services. Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014. 
https://stacks.cdc.gov/view/cdc/26062.  Accessed July 1, 2016. 
45 U.S. Department of Health and Human Services, Health Resources and Services Administration, Guide for 
HIV/AIDS Clinical Care  2014 Edition. Rockville, MD: U.S. Department of Health and Human Services.  
http://hab.hrsa.gov/deliverhivaidscare/2014guide.pdf.  Accessed July 1, 2016. 
    Informational Bulletin  Page 10   
 
Program (RWHAP)46, which has been shown to achieve high rates of retention in care and 
virologic suppression47. 
 
As of August 2016, 19 states and the District of Columbia have a total of 28 approved Medicaid 
Health Home models.  Four of these statesAlabama, New York, Washington, and Wisconsin--
have included HIV-infection among their eligibility criteria.  Wisconsin has elected to focus its 
Health Home model on Medicaid and CHIP beneficiaries who are living with HIV and either 
have, or are at risk of developing, another chronic condition48.  States interested in implementing 
Health Home models that include, or are specifically limited to, PLWH are encouraged to take 
advantage of the technical resource and support available through CMS, including those posted 
on the Health Home Information Resource Center page of Medicaid.gov49.  In particular, states 
may view slides from a 2014 presentation that Wisconsin gave about how it developed its 
HIV/AIDS Health Home50.  
While the Medicaid Health Home option offers states an important new opportunity for 
improving the health of PLWH, CMS would like to remind states that this option is but one tool 
in a broader toolkit that they can use to improve service delivery for the PLWH population.  For 
example, many states have leveraged the Targeted Case Management service option to 
coordinate and improve access to medical, behavioral, and social services for PLWH. In Rhode 
Island, the success of this approach for improving outcomes among PLWH has inspired the state 
to develop a similar set of services for persons at high risk of acquiring HIV51.  Similarly, states 
have long used the Home and Community Based Programs under section 1915(c) of the Act and 
section 1115 Demonstration authorities to develop unique programs to improve PLWH health 
outcomes.  Currently, Alabama, California, Colorado, Florida, Illinois, Iowa, Missouri, New 
Mexico, and South Carolina have approved section 1915 (c) Programs through which they 
provide special, HIV-related services to adult PLWH.  Many others successfully serve 
individuals with HIV/AIDS in their more broadly targeted waivers, which often offer a rich 
                                                           
46 A federal grant program administered by the Health Resource and Services Administration (HRSA) that provides 
primary medical care and essential support services for people living with HIV who are uninsured or underinsured.  
For more information, please visit http://hab.hrsa.gov/.  
47 Doshi RK, Milberg J, Isenberg D et al. (2015). High rates of retention and viral suppression in the US HIV safety 
net system: HIV care continuum in the Ryan White HIV/AIDS Program, 2011.  Clin Infect Dis. 2015; 60 (1): 117-
25.  
48 Wisconsins experience was recently profiled in a case study written by the National Academy for State Health 
Policy, Advancing HIV Prevention through Health Departments: Health Homes for People Living with HIV.  
http://www.nashp.org/wp-content/uploads/2016/06/Wisconsin-Health-Homes_v2_Pages.pdf.  Accessed July 1, 
2016. 
49 Health Home Information Resource Center. https://www.medicaid.gov/state-resource-center/medicaid-state-
technical-assistance/health-homes-technical-assistance/health-home-information-resource-center.html.  Accessed 
July 1, 2016.  
50 Health Home Technical Assistance Learning Forums. https://www.medicaid.gov/state-resource-center/medicaid-
state-technical-assistance/health-homes-technical-assistance/health-homes-ta-learning-forums.html.  Accessed July 
1, 2016. 
51 NASTAD, Financing HIV Prevention Services. https://www.nastad.org/sites/default/files/NASTAD-HIV-
Prevention-Rhode-Island-Case-Study.pdf.  Accessed July 1, 2016.  
    Informational Bulletin  Page 11   
 
service package that can address diverse service needs. States offer a wide range of services 
under section 1915(c) waivers for individuals with HIV/AIDS.    Examples of services that States 
currently offer in 1915(c) HIV/AIDS waivers include the following: Case Management, 
Attendant Care, Home Health, Specialized Medical Equipment and Supplies, Nutritional 
Consultation, Respite, Environmental Modifications and Supplies, Private Duty Nursing, 
Personal Care, Home Maker Services, Personal Assistance, Home Delivered Meals. 
Medicaid and CHIP beneficiaries living with HIV may also be eligible to receive care 
coordination and other support services (e.g., housing support, health education and risk 
reduction, treatment adherence interventions, and medical transportation services) available 
through other federal, state, local, or private programs.  Close coordination and collaboration 
between state Medicaid programs and other programs that support access to HIV prevention, 
care and support services is, however, essential, as those other programs may have strict 
eligibility criteria or other limits on the circumstances under which they can fund and/or provide 
services.  The RWHAP, for example, is required by statute to function as a payer of last resort52.  
As chronicled in a 2013 report from the National Academy for State Health Policy (NASHP), 
state Medicaid programs have developed a variety of strategies for coordinating benefits and 
services with their state RWHAP colleagues53  (e.g., instituting data-sharing agreements or 
having Medicaid representatives sit on state and/or local RWHAP Planning Bodies).   More 
generally, state Medicaid agencies developing new initiatives to improve the care and treatment 
outcomes among PLWH are likely to benefit from sharing their scope of work with federal, state, 
and local partners who are also addressing the needs of PLWH. 
Effective Treatment with ART for People Living with HIV 
As noted in the Background section of this IB, recent studies have shown that ART confers 
substantial clinical benefits on all persons living with HIV who initiate treatmentnot just those 
with advanced immune suppression54,55.  Moreover, there is good reason to believe that the 
                                                           
52 Policy Notice 16-02 Ryan White HIV/AIDS Program Services: Eligible Individuals and Allowable Uses of Funds: 
The RWHAP statute, codified at title XXVI of the Public Health Service Act, stipulates that "funds received...will 
not be utilized to make payments for any item or service to the extent that payment has been made, or can 
reasonably be expected to be made..." by another payment source. At the individual client level, this means 
recipients must assure that funded sub-recipients make reasonable efforts to secure non-RWHAP funds whenever 
possible for services to eligible clients. In support of this intent, it is an appropriate use of RWHAP funds to provide 
case management (medical or non-medical) or other services that, as a central function, ensure that eligibility for 
other funding sources is aggressively and consistently pursued (e.g., Medicaid, CHIP, Medicare, other local or State-
funded HIV/AIDS programs, and/or private sector funding, including private insurance).  
http://hab.hrsa.gov/affordablecareact/service_category_pcn_16-02_final.pdf.  Accessed July 1, 2016. 
53 Witgert K, Dolatshahi J, Yalowich R.  Strategies for Coordination Between Medicaid and Ryan White HIV/AIDS 
Programs, 2013.  Portland, ME: National Academy for State Health Policy (NASHP). 
http://www.nashp.org/sites/default/files/ryanwhite.medicaid.coordination.pdf.  Accessed July 1, 2016.  
54 The INSIGHT START Study Group. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. 
The New England Journal of Medicine (see footnote 11). 
55 TEMPRANO ANRS 12136 Study Group. A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in 
Africa (see footnote 12). 
    Informational Bulletin  Page 12   
 
benefits of early ART extend beyond the immediate outcomes demonstrated under both the 
START and TEMPRANO studies. Evidence suggests that earlier ART initiation may result in 
less residual immune dysfunction during treatment, and this in turn may result in reduced risk of 
not only AIDS-related diseases, but also chronic conditions for which PLWH may be at 
increased risk, including kidney disease, liver disease, cardiovascular disease, neurologic 
complications, and non-AIDS cancers56. 
Providing treatment to people living with HIV infection to improve their health must always be 
the first priority.  However, the potential public health benefits conferred by HIV treatment as a 
preventive measure (or, treatment as prevention) are also sizeable. Recent models from CDC 
indicate that new infections in the U.S. could be reduced by 70% (or, 185,000 infections averted 
by 2020) if NHAS targets for HIV testing and treatment, as well as expanded use of PrEP, were 
attained57.  Even more notable was the outsize role that effective treatment (defined as treatment 
that leads to viral load suppression) played in that modeling scenario: over 90% of the 
aforementioned reduction (i.e., 168,000 of the 185,000 infections prevented) would be due to 
increases in the percentage of PLWH who were on ART and had achieved viral suppression. 
To ensure both the individual and public health benefits of ART are realized among their 
Medicaid and CHIP beneficiaries and in their communities, states should align their Medicaid 
policies and practices with the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected 
Adults and Adolescents (hereafter, the DHHS Guidelines)58. The DHHS Guidelines are 
regularly updated to incorporate new scientific evidence and provide users with comprehensive 
information and recommendations around topics such as baseline laboratory evaluations, benefits 
of ART and considerations when initiating therapy, choice of the initial regimen for ART-naive 
patients, management of treatment failure, management of adverse effects and drug interactions, 
and special ART-related considerations in specific patient populations.  
Given that adherence to ART is a critical prerequisite to realizing both individual and public 
health benefits, states are reminded of the statutory requirement to cover all covered outpatient 
drugs of manufacturers with agreements described section 1927(b) of the Act, including single-
tablet ART regimens.  States can also, and are strongly encouraged to, go farther to support 
access and adherence to effective treatments for PLWH. States should design their prescription 
drug formularies to minimize potential barriers presented by utilization management techniques 
so that Medicaid and CHIP beneficiaries living with HIV can readily access all regimens 
described for potential use (including those labeled as Recommended, Alternative, and 
Other) in the DHHS Guidelines.  
                                                           
56 DHHS, Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents (see footnote 13). 
57 Yaylali E, Farnham P, Jacobson E, Allaire BT, Wagner DL, Hicks KA et al. Impact of Improving HIV Care and 
Treatment and Initiating PrEP in the United States, 2015-2020. Abstract for the Conference on Retroviruses and 
Opportunistic Infections (CROI) in Boston, Massachusetts. February 2225, 2016. Abstract number 1051.  
58 DHHS, Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents (see footnote 13). 
    Informational Bulletin  Page 13   
 
Furthermore, states may also wish to explore ways to better leverage existing Medicaid benefits 
and services to address common treatment adherence challenges following a user centered design 
approach.  For example, adding single-tablet regimens recommended in the DHHS Guidelines to 
preferred drug lists, and removing any step therapy requirements associated with these treatment 
regimens, may increase adherence by reducing patient pill burden, treatment complexity, and 
potential side effects. We also encourage states to refrain from requiring beneficiaries to have 
tried and failed relatively more burdensome, and in some cases, less clinically appropriate 
regimens for reasonable periods of time before single-tablet regimens or other non-preferred 
drugs may be covered. Such step-therapy may not be appropriate for the treatment of HIV and 
may result in poor clinical outcomes for the individual, as well as have public health implications 
due to increased transmission. 
Monitoring and Improving Viral Load Suppression Among PLWH  
Improving rates of viral load (VL) suppression among PLWH is critical to realizing individual, 
population, and community health improvements, as well as any cost savings associated with 
them. Viral load suppression rates also serve as means of gauging how well Medicaid programs 
are meeting the needs of its HIV-infected beneficiaries.   
Measures of performanceespecially when assessed at multiple levels, including the individual 
provider or clinic, health system or health plan, and community or populationare required 
foundations for creating and maintaining systems of care that support continuous quality 
improvements and reward value over volume59,60.   Outcomes-oriented quality measures are 
particularly useful, as they keep attention focused on the end goals of care, rather than 
processes for achieving those goals61.  
Since 2014, CMS has included National Quality Forum (NQF) Measure #2082: HIV Viral Load 
Suppression in its Medicaid Adult Core Set of quality measures62.  More recently, the Core 
Quality Measure Collaborative--a multi-stakeholder initiative led by the Americas Health 
Insurance Plans (AHIP) that included representatives from AHIP members plans, as well as 
CMS, NQF, national physician organizations, employers and consumersreleased seven 
consensus core measure sets that both public and private payers have committed to using for 
reporting as soon as feasible.  NQF 2082: HIV Viral Load Suppression (hereafter referred to as 
                                                           
59 IOM (Institute of Medicine). 2015. Vital signs: Core metrics for health and health care progress. Washington, 
DC: The National Academies Press. http://www.nap.edu/catalog/19402/vital-signs-core-metrics-for-health-and-
health-care-progress.  Accessed July 1, 2016. 
60 Health Care Payment Learning and Action Network (HCPLAN).  Accelerating and Aligning Population-Based 
Payment Models: Performance Measurement.  Draft White Paper. Posted April 2016. http://hcp-
lan.org/workproducts/pm-whitepaper-draft.pdf.  Accessed July 1, 2016. 
61 The operational flexibility and methodological neutrality that characterize outcome measures may be especially 
beneficial in the context of delivery system reform and innovation.  
62The 2016 Adult Core Set, as well as technical guides and resources to support collection of these measures, are 
available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/adult-health-
care-quality-measures.html.  Accessed July 1, 2016. 
    Informational Bulletin  Page 14   
 
the HIV Viral Load Suppression measure) was included in the HIV/Hepatitis C consensus core 
set finalized by the collaborative as well63. 
The HIV Viral Load Suppression measure offers states a concise but informative means for 
tracking and evaluating the quality of care being delivered to their Medicaid and CHIP 
beneficiaries living with HIV.  Moreover, the measure is conceptually aligned with surveillance-
based, public health indicators used to track state and national performance under the National 
HIV/AIDS Strategy, so its adoption and use also allow states to evaluate how improvement 
efforts among their Medicaid and CHIP beneficiaries contribute to state level population health 
improvement and state achievement of NHAS performance targets64.   
Because the HIV Viral Load Suppression measure is an outcome measure, acquiring the data 
necessary to calculate performance can pose challenges to state Medicaid programs (and their 
managed care contractors).  Nonetheless, to date, several states (including New York65, 
Delaware, and Louisiana) have captured and reported results for the HIV Viral Load Suppression 
measure to CMS.  
Spotlight on State Quality Improvement Activities 
The following states are collecting and using HIV-related performance measuresincluding 
measures of viral load suppressionto drive improvements in health outcomes among PLWH.  
  Delaware 
Under federal regulation 42 CFR 438 subpart E, states delivering services to Medicaid 
beneficiaries through managed care arrangements are required to develop a Quality Strategy 
(QS).  The QS is the framework which the state provides objectives and strategies to address 
health care quality, cost and access to health care. Delaware has an approved section 1115 
demonstration program entitled Diamond Health Care Plus. In its latest Quality Management 
Strategy submission, Delaware outlines various HIV-related performance metrics that the state 
would monitor to improve health care outcomes for Medicaid beneficiaries living with 
HIV/AIDS.   In addition, Delaware mandates that managed care contractors must ensure that 
their networks include providers who specialize in the care and treatment of PLWH. 
  Florida 
Under federal regulations 42 CFR 438 subpart E, the parameters are outlined for states to follow 
to conduct external quality review (EQR). An EQR is an evaluation by an external quality review 
                                                           
63 For additional information about the Collaborative, as well as links to the specific core measure sets it developed 
and approved, see https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityMeasures/Core-Measures.html.  Accessed July 1, 2016. 
64National HIV/AIDS Strategy for the United States: Updated to 2020Indicator Supplement. August 2015.  
https://www.whitehouse.gov/sites/default/files/docs/nhas_2020_indicator_supplement_8-15.pdf. Accessed July 1, 
2016. 
65 Recently profiled in a case study written by the National Academy for State Health Policy, Advancing HIV 
Prevention through Health Departments: HIV-Specific Quality Metrics for Managed Care.  
http://www.nashp.org/wp-content/uploads/2016/06/NY-QARR-Case-Study_v7_pages.pdf.  Accessed July 1, 2016.  
    Informational Bulletin  Page 15   
 
organization of information on quality, timeliness and access to health care services provided to 
Medicaid beneficiaries. Florida Agency for Health Care Administration has contracted with a 
number of specialty MCOs to deliver care and treatment to PLWH. As part of their efforts to 
improve health outcomes among enrollees living with HIV, MCOs have undertaken and 
successfully completed a number of Performance Improvement Projects (PIPs) on topics such as 
Viral Load Testing and Reducing Avoidable Emergency Department Visits among PLWH. 
 
  Louisiana 
Louisianas Bureau of Health Services Financing (Louisianas Medicaid program) has overcome 
the technical challenges posed by an outcome measure like HIV Viral Load Suppression by 
developing a novel data sharing arrangement with its Office of Public Health (OPH).  As detailed 
more fully in a recent case study from the National Association of State and Territorial AIDS 
Directors (NASTAD)66, on a quarterly basis, the Bureau of Health Services Financing (BHSF) 
provides OPH with information about all Bayou Health67 members who have had a HIV-related 
claim in a set period of time.  OPH then cross-references that information with its surveillance 
data and, if theres a match (indicative that the individual has previously been diagnosed with 
HIV), provides BHSF individual-level information about whether the person is virally 
suppressed.  BHSF, in turn, communicates the results of OPHs matching process to the 
managed care organizations (MCOs) contracted to deliver care through Bayou Health.  In fact, 
beginning in 2016, Louisiana will not only track and report to CMS on HIV viral load 
suppression rates; it will use the measure to hold MCOs accountable for the quality of care they 
deliver to their enrollees who are PLWH. 
  Maine 
Maine submitted and gained approval under the section 1115 demonstration waiver authority to 
develop an 1115 program with the specific intent to enroll PLWH. Approved in 1998, the 
MaineCare HIV/AIDS Care Demonstration has approximately 800 PLWH currently enrolled 
who were made eligible through the demonstration. The goal of the program is to provide critical 
services to PLWH to delay, prevent or reverse the progression of HIV. Preliminary evaluation 
results have demonstrated that viral load suppression improve for members in the demonstration. 
  New York 
New York has developed various programs utilizing Medicaid authorities to address the care and 
treatment of PLWH. Under New Yorks current Delivery System Reform Incentive Program 
(DSRIP), the state hopes to improve health outcomes by restructuring its healthcare system to 
better integrate preventive and primary care services and supports. To determine whether the 
new systems of care being evaluated under the DSRIP work for potentially complex beneficiary 
populations like PLWH, New York has specifically included HIV-related performance 
                                                           
66 Financing HIV Prevention Services: Collaboration and Innovation between Public Health and Medicaid Agencies.  
National Association of State and Territorial AIDS Directors (NASTAD).  
https://www.nastad.org/sites/default/files/NASTAD-HIV-Prevention-Louisiana-Case-Study.pdf. Accessed July 1, 
2016. 
67 Louisianas Medicaid managed care program 
    Informational Bulletin  Page 16   
 
improvement metrics like viral load suppression among the quality measures it is tracking under 
this waiver program. 
Addressing Substance Use among PLWH  
The United States is experiencing an epidemic of drug overdose (poisoning) deaths.  In 2014, 
more people died from drug overdoses than in any year on record, and the majority of drug 
overdose deaths (more than six out of ten) involve an opioid68.  The individual, health system, 
and public health consequences of this epidemic, however, extend far beyond drug-induced 
morbidity and mortality (e.g., overdose deaths); behaviors associated with abuse of opioids have 
also created ideal conditions for increases in the incidence and prevalence of other, costly public 
health threats, including infections due to blood-borne viruses like hepatitis C (HCV) and HIV.  
Data from CDCs National Notifiable Disease Surveillance System (NNDSS) reveal that from 
2010 through 2014 there was a 158.1% increase in the number of reported cases of acute 
hepatitis C; this emerging epidemic of acute HCV can be readily traced to growing numbers of 
young, non-urban (rural and Appalachian) white youth who have transitioned from oral 
prescription opioid abuse to injection of these opioids and heroin69.  Following a recent outbreak 
of HCV and HIV in Austin, Indiana, CDC conducted an analysis to identify other communities 
at substantial risk of rapid dissemination of IDU-associated HIV, and new or continuing high 
numbers of HCV infections.  That analysis identified 220 counties in 26 states as being 
particularly vulnerable to outbreaks similar to the one in Austin.70 Interventions, like syringe 
service programs (SSPs) or medication-assisted therapy (MAT), thus offer states important tools 
to mitigate Medicaid and CHIP beneficiaries risks of acquiring or transmitting HIV.  CMS has 
previously released a number of Information Bulletins designed to help states identify effective 
practices for identifying and addressing opioid overdoses, misuse, and addiction71.  In addition, 
                                                           
68 Rudd RA, Aleshire N, Zibbell JE, Gladden RM.  Increases in Drug and Opioid Overdose Deaths  United States, 
20002014.  MMWR 2016; 64 (50): 1378-82. 
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w.  Accessed July 1, 2016.   
69 Centers for Disease Control and Prevention.  Viral Hepatitis Surveillance United States, 2014.  
http://www.cdc.gov/hepatitis/statistics/2014surveillance/pdfs/2014hepsurveillancerpt.pdf.  Accessed July 1, 2016.  
70 Van Handel MM, Rose CE, Hallisey EJ et al. (2016).  County-level Vulnerability Assessment for Rapid 
Dissemination of HIV or HCV Infections among Persons who Inject Drugs, United States.  JAIDS; published ahead 
of print.  
http://journals.lww.com/jaids/Citation/2016/11010/County_Level_Vulnerability_Assessment_for_Rapid.13.aspx 
71Best Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction.  Center for Medicaid and 
CHIP Services, CMS, January 2016. https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-02-02-
16.pdf.  Accessed July 1, 2016. 
 
Delivery Opportunities for Individuals with a Substance Use Disorder. Center for Medicaid and CHIP Services, 
CMS, October 2014. https://www.medicaid.gov/federal-policy-guidance/downloads/cib-10-29-14.pdf.  Accessed 
July 1, 2016.  
 
Medication Assisted Treatment for Substance Use Disorders.  Center for Medicaid and CHIP Services, CMS, July 
2014.  http://www.medicaid.gov/federal-policy-guidance/downloads/cib-07-11-2014.pdf. Accessed July 1, 2016. 
    Informational Bulletin  Page 17   
 
CMS recently released a final rule applying Paul Wellstone and Pete Domenici Mental Health 
Parity and Addiction Equity Act of 2008 (MHPAEA) parity requirements to: (1) Medicaid 
managed care organizations (MCOs) as described in section 1903(m) of the  Act ; (2) Medicaid 
benchmark and benchmark-equivalent plans (referred to in this rule as Medicaid Alternative 
Benefit Plans (ABPs)) as described in section 1937 of the Act; and (3) Children's Health 
Insurance Program (CHIP) under title XXI of the Act72. As states continue to develop and 
implement comprehensive strategies for addressing substance use disordersincluding opioid 
addictionwithin their Medicaid and CHIP populations, they should actively consider ways to 
structure benefits and services so that they reduce consequences of substance use and abuse such 
as overdose deaths and HIV transmission.  
The following table summarizes state opportunities to improve HIV prevention and care service 
delivery for Medicaid and CHIP beneficiaries. States interested in learning more about, and/or 
requesting technical assistance around, the opportunities described in this Information Bulletin 
may contact  Dr. Andrey Ostrovsky, Chief Medical Officer, CMCS. 
Key Resources Mentioned in this Bulletin 
1.  National HIV/AIDS Strategy for the United States: Updated to 2020. 
https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas-update.pdf.   
2.  Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of 
antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and 
Human Services. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-
guidelines/0.  
3.   U.S. Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in 
the United States2014 Clinical Practice Guideline. May 2014. 
http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf.   
4.  U.S. Preventive Services Task Force. Final Recommendation Statement: Human 
Immunodeficiency Virus (HIV) Infection: Screening. May 2015. 
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-
immunodeficiency-virus-hiv-infection-screening.  
5.  Medication Assisted Treatment for Substance Use Disorders.  Center for Medicaid and CHIP 
Services, CMS, July 2014.  http://www.medicaid.gov/federal-policy-
guidance/downloads/cib-07-11-2014.pdf. 
6.  2016 Updates to the Child and Adult Core Health Care Quality Measurement Sets. Center 
for Medicaid and CHIP Services, CMS, December 2015. https://www.medicaid.gov/federal-
policy-guidance/downloads/cib-12-11-15.pdf  
                                                           
72 See Medicaid and Childrens Health Insurance Programs; Mental Health Parity and Addiction Equity Act of 2008; 
the Application of Mental Health Parity Requirements to Coverage Offered by Medicaid Managed Care 
Organizations, the Childrens Health Insurance Program (CHIP), and Alternative Benefit Plans at 
https://www.federalregister.gov/articles/2016/03/30/2016-06876/medicaid-and-childrens-health-insurance-
programs-mental-health-parity-and-addiction-equity-act-of  
    Informational Bulletin  Page 2   
 
 
   
    Informational Bulletin  Page 18   
 
 
HIV Prevention/Care Service  Opportunities for Medicaid Programs 
HIV Testing and Diagnosis     Cover USPSTF recommended HIV screening without 
cost sharing for all Medicaid and CHIP beneficiaries  
  Cover HIV screening services when provided by 
unlicensed providers that meet qualifications 
established by the state 
Pre-Exposure Prophylaxis (PrEP)    Ensure that utilization management techniques are not 
designed or implemented in ways that limit access to 
PrEP among persons for whom it is indicated 
  Cover PrEP services, including FDA-approved 
covered outpatient drugs approved for PrEP, as 
recommended in USPHS Guidelines  
Linkage to and Retention in Care    Include HIV-infection among the eligibility criteria 
for People Living with HIV  for state Medicaid Health Home models 
(PLWH)    Leverage Targeted Case Management service options 
and waiver authorities to develop unique programs to 
coordinate and improve access to medical, behavioral, 
and social services for PLWH.  
  Coordinate benefits with other programs that support 
access to HIV prevention, care and support services 
(e.g., Ryan White HIV/AID Program service 
providers) 
Effective Treatment for PLWH    Cover all regimens described for potential use 
(including those labeled as Recommended, 
Alternative, and Other) in DHHS Guidelines for 
providing antiretroviral therapy (ART) to PLWH 
  Design and implement utilization management 
techniques that promote adherence (e.g., include 
single tablet regimens on preferred drug lists) 
 
Monitoring and Improving Viral    Collect and report to CMS results for the HIV Viral 
Load Suppression (VLS) among  Load Suppression measure, which is part of the 
PLWH  Medicaid Adult Core Measure Set 
  Implement the VLS and other HIV prevention and 
care-related quality measures as part of targeted 
quality improvement activities.