Medicare Coverage Change Limits HIV Prevention Care for LGBTQ+ Seniors | Equitas Health

News 5/10/24

Medicare Coverage Change Limits HIV Prevention Care for LGBTQ+ Seniors

Medicare’s pending reclassification of an HIV prevention medication will hinder access to the drug for LGBTQ+ seniors and others who need it most. The Centers for Medicare & Medicaid Services (CMS) in 2023 announced a proposed National Coverage Determination (NCD) for pre-exposure prophylaxis (PrEP) for HIV prevention. In April 2024, CMS then indicated that PrEP coverage will soon move from Medicare Part D (drug coverage) to Medicare Part B (medical insurance). The Centers for Disease Control and Prevention (CDC) notes that “PrEP reduces the risk of getting HIV from sex by about 99% when taken as prescribed.”

CMS’ decision to change coverage from Medicare Part D to Medicare Part B will adversely impact access to care for LGBTQ+ seniors and others at risk of HIV. Many pharmacies across the country – ranging from small, independent operations to large, retail-chain stores – are unable to bill effectively and accurately to Medicare Part B.

This key logistical problem will harm LGBTQ+ seniors and others at risk of HIV by inadvertently limiting their access both to PrEP and PEP (post-exposure prophylaxis) for HIV prevention. The change also will have a disparate impact on men who have sex with men (MSM), people of color, and others who are over-represented among seniors living with HIV.

“Despite medical advances, HIV remains a chronic and infectious disease that depletes a person’s immune system and accelerates underlying medical conditions,” said David Tessier, MD, interim medical director at Equitas Health. “Left untreated, HIV leads to costly illness and death. No one is immune, and the risks are even greater for older adults, as HIV can accelerate common underlying medical conditions associated with aging. This is why Medicare’s increased restrictions for PrEP are so egregious. Simply put, this puts older Americans at risk of a preventable, deadly disease.”

Regarding access to care for LGBTQ+ seniors, Rhea Debussy, Ph.D., director of External Affairs at Equitas Health, said“In an effort to increase access to care, CMS and the federal government have actually done the opposite. Moving PrEP from Medicare Part D to Part B puts dangerous barriers between our LGBTQ+ elders and the medical care that they deserve.”

Working alongside a broad coalition of HIV/AIDS advocacy organizations, trade organizations, and professional associations, Equitas Health co-drafted a public letter to CMS. The letter outlines concerns about how the coverage change will adversely affect patients and their access to PrEP and PEP nationally. Outlining numerous concerns and recommendations, the coalition also indicated that an estimated 10% of people who may benefit from PrEP are Medicare beneficiaries, which underscores the broader national impact of this issue.

Considering the unintended effects of this change, Jacquelyn Risner-Kissel, PharmD, RPH, associate director of Clinical Pharmacy at Equitas Health, said: “Placing PrEP medications on Part B not only places unnecessary administrative burdens on pharmacies, it also decreases patient access across the nation, as many pharmacies cannot even bill to Part B. Because of this change, patients will come to their pharmacy, expect to pick-up their prescription, and be turned away – sometimes with no other options to access their medication.”

In anticipation of this change, Nick Saltsman, PharmD, RPh, AAHIVP, chief pharmacy officer at Equitas Health, said: “CMS should work with pharmacists to ensure a smooth transition, so that patients can still access their medication.”

At the time of this release, neither CMS nor the federal government have responded to the concerns outlined in the coalition letter.