Federal health plan, Medicare do not cover routine HIV screening as recommended by CDC

Aug 3 2008

Medicare and federal health care plans that provide coverage under the Federal Employees Health Benefit Plan do not offer payment for routine HIV screening of people ages 13 to 64 -- a practice that was recommended by CDC in 2006 -- Bloomberg reports.

According to Bloomberg, FEHBP provides coverage for 8.5 million employees, and Medicare provides coverage for 7.1 million disabled people under age 65. CDC revised its recommendations because risk-based HIV screening often was not covered by insurance, and doctors often did not know which of their patients were considered high risk. In addition, more people outside high-risk groups -- including women, minority groups and people living outside cities -- were contracting the virus.

FEHBP, which costs $35 billion annually, pays 230 regional health plans nationwide to provide care for federal workers, including those employed by CDC, elected officials and their family members. FEHBP does not follow the CDC HIV screening guidelines but instead adheres to an alternative protocol adopted by the U.S. Preventive Services Task Force, which only covers high-risk individuals. In order to support screening recommendations, the task force requires that studies already have demonstrated the testing provides benefits, Ned Calonge, chair of the task force's advisory panel, said. He added that although the CDC guidelines aim to identify more undiagnosed HIV cases, the agency has not proved yet that the guidelines will be successful. "I don't think they have evidence that a universal testing strategy is going to lead to lower infection rates and less HIV," Calonge said, adding, "There are some indications to be optimistic, but optimism and promise aren't proof."

Bernard Branson of CDC said that meeting the task force's requirements could take years. CDC recommended universal testing for pregnant women in 1995, and the task force did not adopt the guidelines for 10 years, Branson said, adding that during those 10 years, studies showed the routine screening prevented thousands of cases of mother-to-child HIV transmission. In addition, another reason to support the CDC testing recommendations is that agency research has found as many as 70% of new HIV cases are transmitted by people who are unaware of their status, Branson said.

Medicare also does not cover routine HIV screening, according to a spokesperson. Although most Medicare beneficiaries are older than age 65 -- the cut-off age under the CDC testing recommendations -- about seven million younger disabled beneficiaries should be screened under the recommendations, Bloomberg reports.

Cornelius Baker, a policy adviser at the National Black Gay Men's Advocacy Coalition, said that risk-based testing particularly endangers blacks in the U.S., about 2% of whom are living with HIV. Many physicians do not ask patients about their sexual behavior and make assumptions about who is at risk of HIV, Baker said, adding that blacks who do not consider themselves at risk will not be tested unless offered routine screening. "Some doctors are still making irrational decisions about HIV testing, deciding whether to screen someone based on what he or she looks like,' Baker said, adding, "I can't imagine any African-American not being screened for sickle-cell disease; why not for HIV, which is higher in prevalence?'

According to Branson, not following the CDC guidelines allows HIV to spread and prevents HIV-positive people from early diagnosis and treatment. "It's a real paradox when one big federal agency makes a recommendation that another big federal agency won't support,' John Bartlett, a Johns Hopkins University physician, said. He added, "I think they've got to catch up. It's a disease that's lethal, and one of the major problems with HIV today is late entry into care."

Some private insurers -- including UnitedHealth Group, Aetna and Cigna -- began covering routine HIV screening soon after the CDC guidelines were released, according to Bloomberg (Lauerman/Goldstein, Bloomberg, 7/31).