Health Law Daily Wrap Up, MEDICAID—OIG REPORTS: Systemic, operational challenges prevent Medicaid enrollees from receiving HIV care, (Oct 2, 2024)

By Patricia K. Ruiz, J.D.

Medicaid is the largest source of insurance for Americans with HIV.

A report by the Office of Inspector General (OIG) details systemic and operational challenges faced by state agencies and Medicaid managed care plans in ensuring HIV care for Medicaid enrollees. The OIG found that CMS has opportunities to further support states and plans in ensuring Medicaid enrollees with HIV receive the care they need, improving health outcomes and preventing new HIV transmissions (OIG Report, OEI-05-22-00242 (Sept. 25, 2024)).

Importance of Medicaid in HIV treatment. Medicaid is the largest source of insurance for Americans with HIV and plays a critical role in supporting such care. The OIG previously found that, in 2021, one in four Medicaid enrollees with HIV may not have received at least one service critical to HIV care. The OIG interviewed select state Medicaid agencies (states) and comprehensive, risk-based Medicaid managed care plans (plans) to explore challenges that contribute to gaps in HIV care, as well as actions that may improve their ability to ensure enrollees with HIV receive needed care.

Systemic issues. States and plans identified two systemic issues that impact enrollees’ abilities to maintain their care and limit the ability of states and plans to address the resulting gaps in care. Unmet health-related social needs, such as housing instability, lack of transportation, lack of childcare, food insecurity, lack of internet or phones, and stigma, affect the ability of enrollees to maintain their care. States and plans also reported difficulty in addressing gaps in care for enrollees with these unmet needs. States reported using Medicaid flexibilities and the availability of support outside of Medicaid to support housing for enrollees and meet other health-related social needs. Since the OIG’s interviews, CMS released guidance on the use of Medicaid flexibilities for health-related social needs, and HHS and the Department of Housing and Urban Development selected nine states to receive federal technical assistance and peer-to-peer support to improve coordination and delivery of services.

States and plans also reported that shortages of HIV care providers impact enrollees’ access to care, timing of care, and quality of care. To help address the impact of provider shortages on HIV care, states and plans aid they trained and/or offered guidance about caring for patients with HIV, but the impact of these efforts has been limited. The OIG noted that, while the training of non-HIV care provider to work with people with HIV could help alleviate the impact of HIV provider shortages, there are also workforce shortages among other provider types, such as primary care physicians. Preparing providers to work with patients with complex needs such as HIV may also require decreased workloads and additional compensation.

Operational issues. States and plans identified two operational challenges—limited access to data and insufficient administrative staff—that impact the ability of states and plans to monitor enrollees’ care needs and connect enrollees to care. The data includes enrollees’ viral load levels, Medicare claims for dually eligible enrollees, and other data currently unavailable in Medicaid claims. The OIG found that some states could not access surveillance data to assess viral suppression for Medicaid enrollees, while others can access this data with some limitations. For dual eligible enrollees, states reported having access to some, but not all, claims for services paid for Medicare. As a result, states may allocate resources to care coordination to address gaps that do not exist. States and plans also identified types of data that could help them monitor the care of enrollees with HIV and take action where needed, such as enrollees’ sexual orientation and gender identity and relevant health-related social needs.

States and plans said that insufficient administrative staffing within heir programs and plans impacts the ability to identify and coordinate care needs. Further, limited administrative staffing affected efforts to access and use data that could help them monitor care and outcomes of enrollees with HIV, such as viral load data and viral suppression data. States reported using contractors as workarounds to meet program needs despite staffing shortages.

Recommendations. The OIG found that CMS has opportunities to further support states and plans in ensuring Medicaid enrollees with HIV receive the care they need, improving health outcomes and preventing new HIV transmissions. The OIG recommended that CMS: (1) pursue further actions to help states share knowledge with each other and coordinate internally regarding strategies to ensure needed care for Medicaid enrollees with HIV; and take additional steps to help states leverage the State Data Resource Center to access and use Medicare data for dually eligible enrollees with HIV. CMS concurred with both of the OIG’s recommendations.

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