Health-Based Payment for HIV/AIDS in Medicaid Managed Care Programs

Health Care Financing Review, Spring, 1998 by Richard Conviser, Sandy Gamliel, Lynda Honberg

Table 1 Special AIDS Capitation Rates in State Medicaid Programs

Program and                 Waiver      Eligibility
Region or State             Authority   Criteria

AIDS Healthcare             1915(b)     1993 CDC
 Foundation, Los Angeles    Voluntary   AIDS Definition

California Two-Plan         1915(b)     1993 CDC
 Counties(3)                Voluntary   AIDS Definition

CalOPTIMA, Orange County,   1915(b)     1993 CDC
 California                 Mandatory   AIDS Definition

HealthChoice, Maryland      1115        1993 CDC
                            Mandatory   AIDS Definition

Massachusetts               1915(b)     (6)HIV  Test, CD4 Count
                            Voluntary   Less Than 200 or Percentage
                                        Below 14, Treatment Within
                                        Past 12 Months for Active
                                        or Advanced AIDS

Enhanced Capitation         1115        (7)CD4 Count Less Than 200,
 Rate, New York State       Mandatory   Certain ICD-9 Codes, State
                            (Planned)   AIDS Registry Certification

Special Needs Plan,         (9)1115     HIV or AIDS and
 New York State             Voluntary   Uninfected Family
                            (Planned)   Members to Age 19

Accessing Batter Care,      Pilot       1993 CDC
 Ohio                       Program     AIDS Definition

Salt Lake County, Utah      Voluntary   1993 CDC
                                        AIDS Definition

Program and                 Protease     Viral-Load
Region or State             Inhibitors   Testing

AIDS Healthcare             Excluded     Included
 Foundation, Los Angeles

California Two-Plan         Included     Included
 Countries(3)

CalOPTIMA, Orange County,   Included     Included
 California

HealthChoice, Maryland      Excluded     Excluded

Massachusetts               Excluded     Included

Enhanced Capitation         Excluded     Included
 Rate, New York State

Special Needs Plan,         Excluded     Included
 New York State

Accessing Batter Care,      Included     Included
 Ohio

Salt Lake County, Utah      Excluded     Included

Program and                                        Capitation
Region or State             Other                  Rate(s)(1)

AIDS Healthcare             Excludes               (2)$1,139
 Foundation, Los Angeles                           Inpatient Cam

California Two-Plan         -                      $1,000-1,070
 Countries(3)

CalOPTIMA, Orange County,   Excludes Mental        (4)$1,722
 California                 Health, Dental, SNF,
                            and Pharmacy

HealthChoice, Maryland      Excludes               (5)$2,161
                            Children               Baltimore, $1,812
                                                   Elsewhere

Massachusetts               -                      $2,300 Active
                                                   AIDS, $2,988
                                                   Advanced AIDS

Enhanced Capitation         -                      (8)Increase Based
 Rate, New York State                              on AIDS
                                                   Enrollment

Special Needs Plan,         -                      To Be Determined
 New York State

Accessing Batter Care,      (10)2 counties         (11)Variable
 Ohio

Salt Lake County, Utah      -                      $1,198 Plus
                                                   Eligibility
                                                   Category Rate