Department of Health and Human Services Office of Inspector General One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 Ann Maxwell Deputy Inspector General for Evaluation and Inspections August 2023, OEI-05-22-00240 U.S. Department of Health and Human Services Office of Inspector General Data in Brief August 2023, OEI-05-22-00240 One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 Why OIG Did This Review Key Results Human Immunodeficiency Virus (HIV) is a virus that infects tens of We identified 265,493 enrollees thousands of people in the United States (U.S.) each year. While with HIV nationwide. Of these HIV affects people from all walks of life; the epidemic continues to enrollees, in 2021: disproportionately impact gay and bisexual men; transgender • 72,391 enrollees (27 percent) people; youth ages 13-24; and Black and Hispanic/Latino people. 1 may not have received one People diagnosed with HIV need regular care to improve their of three services critical for health outcomes, reduce HIV-related deaths, and ultimately achieving viral reduce new HIV transmissions. The ultimate goal of HIV care is suppression-a medical visit, to achieve viral suppression-meaning that the amount of HIV in viral load test, or antiretroviral the body is very low or undetectable in viral load tests. 2 At the therapy (ART) prescription. individual level, viral suppression allows people with HIV to stay • 11,316 enrollees (4 percent) healthy, enjoy an improved quality of life, and live longer than if may not have received any they were not virally suppressed. At the population level, viral suppression prevents transmission of HIV because people with of the three services. This is HIV who reach and maintain viral suppression have effectively no particularly concerning risk of passing HIV to others. 3, 4 Lack of viral suppression among because missing these people with HIV is often attributed to appropriate care not being services may mean that these initiated or not being regularly received. 5, 6 The Department of enrollees were at greater risk Health and Human Services (HHS) recognizes the importance of of negative impacts on their HIV care and developed guidelines on the clinical needs of people overall health and greater risk with HIV to achieve viral suppression. 7 of transmitting HIV. The Medicaid program plays a critical role in ensuring that people • Enrollees with Medicaid only with HIV receive care that can improve their ability to achieve and were more likely to have maintain viral suppression. In 2018, Medicaid covered an not received critical services estimated 40 percent of all nonelderly people with HIV in the U.S. 8 People with HIV who are covered by Medicaid also tend be part compared to dual-eligible of populations disproportionately impacted by HIV overall, enrollees. including Black and Hispanic/Latino people. 9 • All States had enrollees with HIV who may not have How OIG Did This Review received critical services, but We reviewed the extent to which the Medicaid enrollees who had HIV diagnoses in their Medicaid or Medicare claims data had State rates varied widely. evidence of critical services in 2021. This review included both enrollees with Medicaid only and those who were enrolled in both Medicaid and Medicare (dual-eligible enrollees). We determined whether these enrollees had evidence in their Medicaid and Medicare claims data of three medical services that are critical for all people with HIV according to HHS guidelines: (1) medical visits (in-person or telehealth), (2) viral load tests, and (3) antiretroviral therapy (ART) prescriptions. Because inaccuracies in claims data could impact our results, we reviewed the completeness of Medicaid claims data for these services and removed States from our analysis where we had concerns. Why This Matters This data brief provides insight into the extent to which people with HIV enrolled in Medicaid had evidence of receiving services that are critical for achieving viral suppression, which is vital to the overall health of people with HIV and for the prevention of HIV transmission. Medicaid enrollees with HIV may have gaps in care for various reasons. For example, the COVID-19 public health emergency had a widespread impact on the health care system, including recommendations for certain patients in seeking care as well as patients' access to services. Our results provide a foundation for understanding the scale of potential gaps in care and where further action may be needed to ensure that Medicaid enrollees with HIV are receiving critical services to increase their likelihood of viral suppression. Future OIG work will shed light on specific challenges and strategies that impact Medicaid programs' abilities to ensure HIV care. Primer on HHS Guidelines on HIV Care HHS developed clinical guidelines that detail select aspects of medical care that people with HIV need to help them achieve and maintain viral suppression. 10 HHS recommends 11 that all people with HIV: Attend regular medical visits with HIV providers to manage care. Monitor their viral load, or the amount of HIV in the body, to determine HIV progression and if antiretroviral therapy (ART) is successfully reducing HIV in the body to achieve and/or maintain viral suppression. Initiate and adhere to ART, medicine prescribed by health care providers to reduce the amount of HIV in the body. 12 HHS guidelines do not recommend specific frequencies for these services that should apply to all people with HIV. For example, HHS notes that there are multiple valid ways to assess whether people with HIV are attending regular medical visits-such as looking for at least two visits that are at least 90 days apart over 1 year, or looking for at least one visit at least every 6 months over a 2-year period. 13 The guidelines also note that appropriate service frequencies can depend on individual care needs. 14, 15 In this review, we used a conservative approach to assess whether Medicaid enrollees with HIV had evidence of services that aligned with these guidelines. Specifically, we determined whether enrollees with HIV had at least one medical visit (in-person or telehealth), viral load test, and/or ART prescription filled at any point in 2021. See Methodology for additional details. FINDINGS In this data brief, Medicaid enrollees with HIV refers to Medicaid enrollees with HIV- related diagnosis codes in their Medicaid or Medicare claims from 2019 or 2020, and evidence of critical services refers to the presence of at least one Medicaid or Medicare claim record for a medical visit (in-person or telehealth), viral load test, or antiretroviral therapy (ART) prescription filled in 2021. This review included Medicaid fee-for-service and Medicaid managed care plan (MCP) claims, as well as Medicare fee-for-service and Medicare Advantage plan claims for dual-eligible enrollees. See Methodology for additional details. About one in four Medicaid enrollees with HIV, nationwide, did not have evidence of one or more critical services in 2021, with the absence of viral load tests being the most common gap in care. In 2021, 72,391 of the 265,493 Medicaid enrollees with HIV did not have evidence of at least one of three services through Medicaid or Medicare in 2021-a medical visit, a viral load test, and/or a filled antiretroviral therapy (ART) prescription- recommended by HHS for all people with HIV. Exhibit 1. Of the three critical services, enrollees were most frequently missing viral load tests in 2021. Source: OIG analysis of Medicaid and Medicare claims among enrollees with HIV, 2021. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Findings | 1 Of the 265,493 enrollees with HIV, 23 percent (61,854 enrollees) did not have evidence of at least one viral load test in 2021, more than for the other two critical services. Without viral load tests, • Medical providers do not know patients' viral load levels to see how well treatment is working and to monitor HIV infection. 16 • CMS and State Medicaid programs cannot determine viral load suppression rates of enrollees with HIV to gauge if the program is meeting their care needs. 17, 18 • National, State and local public health officials cannot track viral suppression of residents and identify where improvements are needed. 19 Over 11,000 Medicaid enrollees with HIV did not have evidence of any of the three services in 2021, which may mean that they were at greater risk of negative health impacts and HIV transmission. In 2021, 11,316 enrollees, or 4 percent of the 265,493 enrollees in Medicaid with HIV, did not have evidence of any of the following: at least one medical visit, viral load test, or ART prescription filled through Medicaid or Medicare in 2021. Enrollees without evidence of any of these services critical for people with HIV are particularly concerning. Without critical services, enrollees with HIV may not be able to achieve and maintain viral suppression. 20 If not virally suppressed, people with HIV have levels of HIV in their body that negatively impact their health and put them at risk for transmitting HIV to HIV-negative sexual partners. 21 Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Findings | 2 Enrollees with HIV in Medicaid only were more frequently missing evidence of critical services than dual-eligible enrollees in 2021. Exhibit 2: Enrollees with Medicaid only were more likely to be missing one or more services compared to dual-eligible enrollees. Source: OIG analysis of Medicaid and Medicare claims among enrollees with HIV, 2021. Enrollees with Medicaid only were also three times more likely to not have evidence of any of the three critical services compared to dual-eligible enrollees-6 percent of 142,307 enrollees compared to 2 percent of 123,186 enrollees respectively. Factors related to programmatic differences between Medicaid and Medicare may contribute to the differences in evidence of critical services between enrollees in Medicaid only and dual-eligible enrollees, for whom Medicare provides primary coverage for most care, 22 including: • Higher Medicare fee-for-service payment rates for physician services compared to Medicaid fee-for-service, which may impact access to care as providers are more likely to accept new patients with Medicare; 23, 24 and • Long-term adherence to care among older adults who have lived with HIV since younger ages and are eligible for Medicare based on age.25 Differences in data quality and completeness between Medicaid and Medicare claims data may also contribute to differences in evidence of critical services between enrollees in Medicaid only and the dually enrolled who received services paid by Medicare. Specifically, OIG has raised concerns about the quality and completeness Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Findings | 3 of national Medicaid data available through the Transformed Medicaid Statistical Information System (T-MSIS). However, the Centers for Medicare and Medicaid Services (CMS) and State efforts have led to ongoing improvements in T-MSIS data. 26, 27 We conducted checks to assess and account for the quality and completeness of T- MSIS data used in our study. Specifically, we reviewed the completeness of codes needed for our analysis by State and excluded States with high percentages of missing codes to minimize the impact of poor data quality on our results-see Methodology for additional details. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Findings | 4 All States in this review had enrollees with HIV who did not have evidence of one or more critical services in 2021, but State rates varied widely. All States included in this review, including the District of Columbia, had enrollees in Medicaid only and dual-eligible enrollees without evidence of one or more of the three critical services in 2021. See Appendix A and Appendix B for more details on evidence of critical services for individual States. The proportion of Medicaid-only enrollees missing one or more services varied across States, from 16 percent to 87 percent. We identified four States as outliers on the basis of proportions of Medicaid-only enrollees who did not have evidence of one of the three critical services that were significantly higher than for other States: Arizona (59 percent), Arkansas (60 percent), the District of Columbia (61 percent), and Utah (87 percent). Exhibit 3: Many (20 of 47 States) State rates for Medicaid-only enrollees without evidence of one or more services fell between 24% and 35%. Source: OIG analysis of Medicaid claims among Medicaid enrollees with HIV, 2021. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Findings | 5 The proportion of dual-eligible enrollees who did not have evidence of one or more services also varied across States, from 9 percent to 53 percent. We identified three States as outliers on the basis of proportions of dual-eligible enrollees who did not have evidence of one of the three critical services that were significantly higher than for other States: Alaska (38 percent), West Virginia (47 percent), and South Dakota (53 percent). Exhibit 4: Half (26 of 51 States) of State rates for dual-eligible enrollees without evidence of one or more services fell between 17% and 22%. Source: OIG analysis of Medicaid and Medicare claims among dual-eligible enrollees with HIV, 2021. While these State-specific rates provide a means of comparison across States that account for population differences, they can hide differences in the actual number of enrollees with HIV who did not have evidence of services across States. For example, South Dakota had a higher rate (34 percent) of Medicaid-only enrollees without evidence of one or more critical services than Louisiana (23 percent); however, South Dakota had far fewer actual Medicaid-only enrollees (25) without evidence of critical services than did Louisiana (1,663). Data quality and completeness may contribute to differences in evidence of critical services for Medicaid enrollees with HIV across States. As previously discussed, OIG has raised concerns about T-MSIS data quality and completeness, although improvements have been made over time. Even with the data quality checks we conducted for this study, State differences in T-MSIS data quality and completeness may impact our results. The types of challenges States face in improving HIV care for their enrollees, as well as the most effective strategies for doing so, may also depend on the specific characteristics of each State's Medicaid program and enrollee population. State Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Findings | 6 Medicaid programs vary significantly in size (e.g., number of enrollees, staff, and resources) and structure (e.g., use of managed care, eligibility for Medicaid, and other policy options), and this variation could impact the feasibility or value of different approaches across States. 28, 29 For example, States that have very few enrollees with HIV missing critical services may be able to conduct individual outreach, while this may not be practical in States with hundreds or thousands of enrollees missing critical services. Our future work will dig deeper into the specific challenges States face in ensuring care for enrollees with HIV and strategies they use to try to overcome those challenges. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Findings | 7 CONCLUSION Our finding in this data brief-that in 2021, over a quarter of Medicaid enrollees with HIV did not have evidence in their claims data of receiving one or more critical services-demonstrates that further action is needed to ensure that enrollees are receiving appropriate HIV care. Of particular concern, over 11,000 enrollees did not have evidence of receiving any of the three services we reviewed. These services are recommended by HHS for all people with HIV, and are vital to their overall health as well as the prevention of HIV transmission within the general population. Future OIG work will examine efforts by State Medicaid agencies, Medicaid managed care plans, and CMS to ensure that Medicaid enrollees with HIV receive critical services. That work will cover strategies used and challenges faced, and will focus on actionable steps that these entities can take to improve HIV care in Medicaid. CMS and States may wish to consider taking more immediate steps to address the potential gaps in care that we found. For example, States may wish to follow-up with Medicaid-only enrollees with HIV who do not have evidence of critical services, or with their providers, to ensure that these enrollees can readily access all necessary care. Similarly, CMS may wish to follow-up with dual-eligible enrollees with HIV who do not have evidence of critical services, given Medicare's role as the primary payer for their services. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Conclusion | 8 METHODOLOGY We based this review on an analysis of data from (1) the Transformed Medicaid Statistical Information System (T-MSIS)-the national Medicaid claims and encounter database for all 50 States and D.C., and (2) Medicare National Claims History (NCH) files, Medicare Encounter data, Medicare Prescription Drug Event (PDE) data, and the Medicare Enrollment DataBase (EDB). 30, 31, 32, 33 This review includes services and prescriptions that Medicaid enrollees received through Medicaid (including the Children's Health Insurance Program (CHIP)) and Medicare (if enrolled in both programs). T-MSIS Data Quality Because of ongoing concerns with the quality of T-MSIS data, we assessed the completeness of key variables used in our analysis to ensure that incomplete claims did not significantly limit our ability to identify evidence of critical HIV services for Medicaid-only enrollees. For the viral load tests and medical visit measures, we first identified the claim types most frequently associated with procedure codes for these two services among all 2021 claims for enrollees with HIV. We found that medical visits were almost always associated with professional (i.e., physician office) claims, whereas viral load tests were associated with both professional claims and hospital outpatient claims. We then reviewed the completeness of the procedure code variable for both professional and hospital outpatient claims in each State. For the ART measure, we reviewed the completeness of the National Drug Code (NDC) variable (used to identify ART prescriptions) for RX claims in each State. 34 We removed States from measures in our analysis if the completeness of the key variable for associated claims fell below thresholds that CMS uses in the Data Quality (DQ) Atlas to identify "high concern" or "unusable" data for similar claim types. 35 On the basis of these criteria, we excluded four States (Illinois, Maryland, New York, and Vermont) from the viral load test measure in our analysis due to high rates of missing procedure codes in their hospital outpatient claims. We did not exclude any States from the ART or medical visit measures in our analysis. We further excluded Medicaid-only enrollees in these four States from our national analyses across all three measures. Dual-eligible enrollees in these States were included in the national analyses because Medicare provides primary coverage for most care. 36 Though they are not included in our national analyses, we report results for the ART and medical visit measures for Medicaid-only enrollees in these States in Appendix B. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Methodology | 9 Identifying Enrollees with HIV To identify enrollees with HIV, we reviewed 2019 and 2020 Medicaid and Medicare claims data for enrollees with HIV-related diagnosis codes and Diagnosis Related Group (DRG) codes as defined in CMS's Chronic Conditions Data Warehouse (CCW) algorithm. 37 We made minor modifications to the algorithm by adding codes to include pregnant people with HIV and excluding obsolete codes. We looked for HIV diagnoses in 2019 and 2020, instead of 2021, so that our analysis of enrollees with documented HIV diagnosis did not include people who were newly diagnosed with HIV in the same year that we looked for services. Newly diagnosed people with Medicaid may have what appear to be gaps in their care in the year of diagnosis that are related to when they were diagnosed (i.e., earlier in the year versus later) and/or the onset of HIV treatment (e.g., a delay in starting ART to allow a person with HIV and their provider to assess and address potential barriers to treatment adherence). 38 For enrollees identified with HIV, we used 2021 Medicaid enrollment data to determine whether anyone was not continuously enrolled in Medicaid for all 365 days of 2021. We excluded enrollees who were not continuously enrolled from our analysis to limit the possibility that evidence of missing care was due to enrollment gaps. In 2021, most enrollees were continuously enrolled, as coverage for Medicaid coverage was protected under the COVID-19 public health emergency. 39 Gaps in Critical Services Analysis For each person with HIV, we used their 2021 Medicaid FFS and managed care plan (MCP) claims (and Medicare FFS and Medicare Advantage plan claims, if they were enrolled in Medicaid and Medicare) to find evidence of the three critical services. We adapted and operationalized HHS care guidelines in claims data (e.g., codes, timeframe, scope) to meet our study objective. To do so, we consulted with Health Resources and Services Administration (HRSA) experts to learn about specific code sets and expectations for frequencies of services based on their experiences operationalizing measurement of these three critical services as part of their Ryan White HIV/AIDS Program performance measures. 40 From this learning, we used a conservative approach to our review by searching for evidence of just one instance of each of the three critical services at any point in 2021. Specifically, we reviewed 2021 claims data for: • At least one claim with a code indicating an outpatient medical visit (in-person or telehealth) for evaluation and management; • At least one claim with a procedure code for a quantitative viral load test; and • At least one claim with a National Drug Code (NDC) associated with an HIV antiretroviral therapy (ART) prescription that was filled. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Methodology | 10 We then calculated the proportion of enrollees who did not have evidence of all three critical services nationally, by type of enrollment (Medicaid only or dual-eligible), and by State. To determine national results, we summed the number of enrollees who did not have evidence of at least one of the three critical services in 2021 and divided it by the total number of enrollees with HIV. We also summed the number of enrollees who did not have evidence of any of the three critical services in 2021 and divided by the total number of enrollees with HIV. To determine results by type of enrollment, we calculated the proportion of enrollees who did not have evidence of all three critical services by Medicaid and Medicare enrollment. Specifically, we used Medicaid and Medicare enrollment files to determine if enrollees with HIV were enrolled in Medicaid only or dual-eligible in 2021. Then, we summed the total number of enrollees with HIV with Medicaid only who did not have evidence of at least one of the three services in 2021 and divided it by the total number of enrollees with HIV who were enrolled in Medicaid only. Further, we summed the total number of these Medicaid-only enrollees who did not have evidence of any of the three services in 2021 and divided by the total number of enrollees with HIV who were enrolled in Medicaid only. We conducted similar calculations for dual-eligible enrollees. We summed the total number of dual-eligible enrollees who did not have evidence of at least one of the three services in 2021 and divided it by the total number of dual-eligible enrollees with HIV. Further, we summed the total number of these dual-eligible enrollees who did not have evidence of any of the three services in 2021 and divided by the total number of dual-eligible enrollees with HIV. To determine results by State, we calculated the proportion of enrollees with HIV who did not have evidence of each of the three services and evidence of all three critical services across States. We conducted this analysis separately for enrollees with Medicaid only and dual-eligible enrollees. To do so, we identified the States in which enrollees with HIV were enrolled and received services in 2021. We excluded enrollees who were enrolled or received services in multiple States from this State- level analysis. Then we summed the number of enrollees in each State who did not have evidence of at least one of the three critical services in 2021 and divided by the total number of enrollees with HIV in the State. Similarly, we summed the number of enrollees in each State who did not have evidence of any of the three critical services in 2021 and divided by the total number of enrollees with HIV in the State. See Appendix A. Finally, we summed the number of enrollees with Medicaid only and dual-eligible enrollees in each State who did not have evidence of each service in 2021 and divided by the total number of Medicaid-only and dual-eligible enrollees with HIV in the State. See Appendix B. We also used the Tukey method to identify outliers in States' proportion of enrollees with HIV who (1) were missing one or more of the critical services or did not have evidence of all three critical services (see Appendix A) and (2) did not have evidence of each of the three individual services (see Appendix B). 41 Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Methodology | 11 Limitations Our review focuses on three services critical for all people with HIV; however, individual care needs could warrant different recommendations. For example, providers may delay ART prescriptions briefly for some people with HIV with specific infections. 42 Also, Federal guidance in 2021 on considerations for COVID-19 advised people with HIV to weigh the risks and benefits of attending versus not attending in- person HIV-related clinic appointments. 43 However, our analysis does include medical visits provided via telehealth, which was used to help continue care during the COVID-19 public health emergency. 44 Further, this analysis is based on Medicaid and Medicare claims data available; it is not based on a review of medical records. Any inaccuracies in claims data could impact our analysis. For example, some claims may have incorrectly included HIV-related diagnosis codes, leading us to determine that the enrollee had HIV when they, in fact, did not. Also, if service claims were missing, incorrect, or billed through bundled payments, we could have underestimated actual evidence of critical services. Further, because OIG has raised concerns about T-MSIS data quality and completeness in the past, we reviewed our Medicaid data for completeness and made some exclusions to minimize the impact of incomplete data on our results. Finally, this review only covers services paid for by Medicare or Medicaid. It does not capture any services and prescriptions enrollees received that were not paid for by Medicaid or Medicare, such as those covered by TRICARE or paid for out of pocket. Enrollees who received critical services that were not paid for by Medicaid or Medicare, including Medicaid-only enrollees with limited benefits, may have what appear to be gaps in their services. Standards We conducted this study in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Methodology | 12 APPENDIX A Enrollees without Evidence of Services by State State Enrollees with HIV Missing One or More Services Missing All Three Services Medicaid Only Dual-Eligible Medicaid Only Dual-Eligible Medicaid Only Dual-Eligible n n n % n % n % n % Alabama 1289 1820 292 23% 327 18% 70 5% 33 2% Alaska 226 98 65 29% 37 38% 14 6% - - Arizona 3994 1738 2341 59% 340 20% 329 8% 30 2% Arkansas 745 716 450 60% 195 27% 225 30% 21 3% California 28596 13792 8514 30% 2997 22% 2026 7% 242 2% Colorado 2602 1014 691 27% 208 21% 199 8% 22 2% Connecticut 3085 1939 614 20% 266 14% 125 4% 16 1% Delaware 831 543 188 23% 105 19% 45 5% 15 3% District of 4134 1952 2528 61% 415 21% 269 6% 46 2% Columbia Florida 11806 16655 4929 42% 3389 20% 987 8% 374 2% Georgia 4407 5305 1915 43% 1358 26% 280 6% 104 2% Hawaii 445 300 126 28% 28 9% 32 8% - - Idaho 190 153 30 16% 26 17% - - - - Illinois NR 3758 NR NR 1023 27% NR NR 106 3% Indiana 2332 1541 660 28% 275 18% 139 6% 23 1% Iowa 707 393 131 19% 44 11% 41 6% - - Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Appendix A | 13 Kansas 177 334 33 19% 48 14% - - - - Kentucky 1978 789 536 27% 152 19% 119 6% 16 2% Louisiana 7116 3364 1663 23% 589 18% 464 7% 59 2% Maine 400 400 80 20% 42 11% 18 5% - - Maryland NR 3359 NR NR 700 21% NR NR 36 1% Massachusetts 5810 4220 2409 41% 730 17% 477 8% 47 1% Michigan 5120 2239 1645 32% 565 25% 275 7% 46 2% Minnesota 1933 884 415 21% 117 13% 66 3% 16 2% Mississippi 1050 1502 274 26% 256 17% 53 5% 21 1% Missouri 1061 1886 227 21% 276 15% 50 5% 26 1% Montana 166 81 70 42% 13 16% - - - - Nebraska 174 202 28 16% 35 17% - - - - Nevada 2298 721 903 39% 188 26% 178 8% 22 3% New Hampshire 219 134 39 18% 26 19% - - - - New Jersey 6118 2824 1657 27% 616 22% 218 4% 57 2% New Mexico 1145 550 357 31% 83 15% 81 7% 13 2% New York NR 16266 NR NR 3926 24% NR NR 207 1% North Carolina 3420 4352 1248 36% 632 15% 301 9% 58 1% North Dakota 73 39 17 23% - - - - - - Ohio 6517 2808 1815 28% 592 21% 316 5% 48 2% Oklahoma 464 679 139 30% 143 21% 41 9% 18 3% Oregon 1772 1004 495 28% 170 17% 91 5% - - Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Appendix A | 14 Pennsylvania 10045 5240 3040 30% 934 18% 359 4% 59 1% Rhode Island 681 411 137 20% 58 14% 22 3% - - South Carolina 1776 2350 448 25% 283 12% 147 3% 22 1% South Dakota 73 87 25 34% 46 53% - - - - Tennessee 1925 2184 567 29% 452 21% 89 5% 65 3% Texas 5810 7437 1894 33% 1665 22% 461 8% 170 2% Utah 396 208 343 87% 40 19% 29 6% - - Vermont NR 156 NR NR 31 20% NR NR - - Virginia 4184 2126 1630 39% 423 20% 222 5% 36 2% Washington 2973 1403 778 26% 227 16% 152 5% 28 2% West Virginia 528 295 283 54% 138 47% 34 6% 11 4% Wisconsin 1494 893 362 24% 114 13% 87 6% - - Wyoming 22 42 - - - - - - - - NR Not Reported due to concerns with T-MSIS data quality. Shaded cells are rates that we identified as outliers compared to those of other States. -Number of enrollees was 10 or under and therefore results not reported to protect enrollee privacy. 45 Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Appendix A | 15 APPENDIX B Enrollees without Evidence of Each Service by State State Enrollees with HIV Missing Medical Visits Missing Viral Load Tests Missing ART Prescription Filled Medicaid Only Dual-Eligible Medicaid Only Dual-Eligible Medicaid Only Dual-Eligible Medicaid Only Dual-Eligible n n n % n % n % n % n % n % Alabama 1289 1820 118 9% 53 3% 240 19% 294 16% 195 15% 166 9% Alaska 226 98 19 8% - - 64 28% 35 36% 23 10% - - Arizona 3994 1738 871 22% 65 4% 2153 54% 307 18% 578 15% 141 8% Arkansas 745 716 357 48% 53 7% 343 46% 170 24% 267 36% 87 12% California 28596 13792 4096 14% 1143 8% 7410 26% 2215 16% 3596 13% 1033 8% Colorado 2602 1014 337 13% 43 4% 614 24% 185 18% 365 14% 78 8% Connecticut 3085 1939 239 8% 59 3% 510 17% 207 11% 284 9% 112 6% Delaware 831 543 84 10% 23 4% 161 19% 98 18% 104 13% 51 9% District of 4134 1952 1219 30% 147 8% 2101 51% 341 18% 419 10% 174 9% Columbia Florida 11806 16655 2208 19% 790 5% 4222 36% 3052 18% 1821 15% 1514 9% Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Appendix B | 16 Georgia 4407 5305 483 11% 238 5% 1797 41% 1266 24% 598 14% 434 8% Hawaii 445 300 55 12% - - 91 20% 22 7% 73 16% - - Idaho 190 153 - - - - 29 15% 23 15% - - 12 8% Illinois 8738 3758 1600 18% 252 7% NR NR 908 24% 1672 19% 529 14% Indiana 2332 1541 256 11% 41 3% 578 25% 257 17% 292 13% 120 8% Iowa 707 393 58 8% - - 116 16% 37 9% 81 12% 20 5% Kansas 177 334 12 7% - - 29 16% 42 13% 17 10% 22 7% Kentucky 1978 789 210 11% 36 5% 456 23% 130 17% 282 14% 70 9% Louisiana 7116 3364 813 11% 145 4% 1438 20% 537 16% 860 12% 265 8% Maine 400 400 27 7% - - 75 19% 37 9% 37 9% 18 5% Maryland 7707 3359 1048 14% 132 4% NR NR 610 18% 743 10% 284 9% Massachusetts 5810 4220 1230 21% 150 4% 1472 25% 647 15% 1299 22% 205 5% Michigan 5120 2239 604 12% 95 4% 1484 29% 532 24% 604 12% 257 12% Minnesota 1933 884 156 8% 27 3% 369 19% 107 12% 151 8% 49 6% Mississippi 1050 1502 75 7% 48 3% 250 24% 234 16% 142 14% 106 7% Missouri 1061 1886 94 9% 57 3% 200 19% 250 13% 116 11% 145 8% Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Appendix B | 17 Montana 166 81 17 10% - - 68 41% 12 15% 22 13% - - Nebraska 174 202 - - - - 27 16% 34 17% 13 8% 20 10% Nevada 2298 721 371 16% 54 8% 777 34% 164 23% 404 18% 88 12% New Hampshire 219 134 - - - - 34 16% 24 18% 19 9% 15 11% New Jersey 6118 2824 516 8% 136 5% 1454 24% 557 20% 759 12% 324 12% New Mexico 1145 550 170 15% 24 4% 324 28% 76 14% 154 13% 35 6% New York 34644 16266 5902 17% 1095 7% NR NR 3296 20% 3616 10% 1203 7% North Carolina 3420 4352 505 15% 126 3% 798 23% 567 13% 855 25% 302 7% North Dakota 73 39 - - - - 17 23% - - - - - - Ohio 6517 2808 648 10% 114 4% 1648 25% 539 19% 749 12% 243 9% Oklahoma 464 679 69 15% 34 5% 119 26% 124 18% 76 16% 80 12% Oregon 1772 1004 192 11% 37 4% 445 25% 147 15% 182 10% 57 6% Pennsylvania 10045 5240 1192 12% 194 4% 2485 25% 821 16% 820 8% 384 7% Rhode Island 681 411 41 6% 15 4% 120 18% 47 11% 57 8% 29 7% South Carolina 1776 2350 225 13% 53 2% 362 20% 243 10% 275 16% 142 6% South Dakota 73 87 - - - - 24 33% 45 52% 20 27% 45 52% Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Appendix B | 18 Tennessee 1925 2184 160 8% 109 5% 485 25% 401 18% 297 15% 249 11% Texas 5810 7437 873 15% 437 6% 1595 28% 1463 20% 1036 18% 730 10% Utah 396 208 35 9% - - 88 22% 34 16% 338 85% 22 11% Vermont 156 156 17 11% - - NR NR 27 17% 24 15% 15 10% Virginia 4184 2126 416 10% 78 4% 1507 36% 382 18% 476 11% 180 9% Washington 2973 1403 305 10% 64 5% 691 23% 203 15% 293 10% 91 7% West Virginia 528 295 55 10% 15 5% 268 51% 135 46% 77 15% 44 15% Wisconsin 1494 893 156 10% 15 2% 312 21% 104 12% 156 10% 45 5% Wyoming 22 42 - - - - - - - - - - - - NR Not Reported due to concerns with T-MSIS data quality. Shaded cells are rates that we identified as outliers compared to those of other States. -Number of enrollees was 10 or under and therefore results not reported to protect enrollee privacy. 46 Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Appendix B | 19 ACKNOWLEDGMENTS AND CONTACT Acknowledgments Lisa Minich and Danielle Noriega served as the team leaders for this study, and Jonathan Carroll served as lead analyst. Others in the Office of Evaluation and Inspections who supported this study include Rebecca Gorges and Kayla Phelps. Office of Evaluation and Inspections headquarters staff who provided support include Kevin Manley, Lyndsay Hopper, and Sara Swisher. This report was prepared under the direction of Laura Kordish, Regional Inspector General for Evaluation and Inspections in the Chicago regional office; Adam Freeman, Deputy Regional Inspector General; and Hilary Slover, Assistant Regional Inspector General. Contact To obtain additional information concerning this report, contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found on the OIG website at oig.hhs.gov. Office of Inspector General U.S. Department of Health and Human Services 330 Independence Avenue, SW Washington, DC 20201 Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Acknowledgments and Contact | 20 ENDNOTES 1 CDC, HIV by Group, 2022. CDC identified certain groups that are at higher risk for HIV including intersectionality of demographics. Accessed at https://www.cdc.gov/hiv/group/index.html#print on February 3, 2023. 2CDC, Understanding the HIV Care Continuum, 2019. See "What is the HIV Care Continuum?" Accessed at https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf on May 15, 2023. 3 Ibid. 4CDC, HIV Treatment as Prevention, 2023. Accessed at https://www.cdc.gov/hiv/risk/art/index.html#:~:text=If%20taken%20as%20prescribed%2C%20HIV,HIV%20per%20milliliter%20 of%20blood on August 11, 2023. 5Hughes, For adults with HIV, lack of viral suppression linked to lower care engagement and increased barriers to care, 2021. Accessed at https://www.wolterskluwer.com/en/news/for-adults-with-hiv-lack-of-viral-suppression-linked-to-lower-care- engagement on May 3, 2023. Resource based on Dasgupta et al., Barriers to HIV Care by Viral Suppression Status Among US Adults with HIV: Findings from the Centers for Disease Control and Prevention Medical Monitoring Project, 2021. Accessed at https://journals.lww.com/janac/Citation/2021/10000/Barriers_to_HIV_Care_by_Viral_Suppression_Status.5.aspx on May 3, 2023. 6Only 66 percent of people diagnosed with HIV are virally suppressed due to poor adherence to the continuum of care and to ART. See "Introduction" on page 387/L-2 of HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines- adult-adolescent-arv.pdf on May 3, 2023. 7 HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. See page 15/A1 for overview of the guidelines. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent- arv/guidelines-adult-adolescent-arv.pdf on May 3, 2023. 8KFF, Medicaid and People with HIV, 2023. Accessed at https://www.kff.org/hivaids/fact-sheet/medicaid-and-hiv/#footnote- 432737-5 on May 26, 2021. 9KFF, Insurance Coverage and Viral Suppression Among People with HIV, 2018. See Figure 5. Accessed at https://www.kff.org/hivaids/issue-brief/insurance-coverage-and-viral-suppression-among-people-with-hiv-2018/ on May 3, 2023. 10HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. See page A1 for overview of the guidelines. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent- arv/guidelines-adult-adolescent-arv.pdf on February 6, 2023. 11CDC and HRSA also endorse ART, regular medical visits, and viral load testing for people with HIV. See CDC, Understanding Care, 2021. Accessed at https://www.cdc.gov/hiv/basics/livingwithhiv/understanding-care.html on February 8, 2023. Also see HRSA, HIV/AIDS Bureau Performance Measures, 2019. Accessed at https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/core-measures.pdf on January 2, 2023. 12 HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. See pages 30-31/C-9-10 for guidelines on viral load monitoring, pages 64/E-1 and 65/E-2 for ART recommended for all people with HIV, and pages 387/L- 2 and 388-389/L-3-L-4 for details on engaging in appointments (retention in care). Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf on May 11, 2023. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Endnotes | 21 13HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. See pages 387/L-2 and 388- 389/L-3-L-4 for details on engaging in appointments (retention in care). Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf on April 17, 2023. 14Regarding the recommended frequency for viral load testing, for example, HHS guidelines note that people with HIV who are on ART and have been virally suppressed for over a year may monitor their viral load levels every 6 months, while those who are starting an ART regimen or are not yet virally suppressed may monitor their levels more frequently. HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. See page 22/C-1 and Table 3, page 24/C-3, for recommended schedule of viral load tests. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf on April 17, 2023. 15 Though HHS recommends that all people with HIV initiate ART, it also recommends that clinicians consider patients' readiness for ART including assessments of substance use, social support, mental health, etc., and manage those factors accordingly. See HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. See pages 19/B- 1 for ART recommended for all people with HIV and recommendation to initiate ART immediately after HIV diagnosis. Also see page 20/B-2 for recommendation to assess patient readiness for ART. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf on January 3, 2022. 16 MedlinePlus, HIV Viral Load. Accessed from https://medlineplus.gov/lab-tests/hiv-viral- load/#:~:text=A%20viral%20load%20test%20is%20needed%20to%20guide%20treatment%20decisions.&text=This%20informa tion%20helps%20your%20provider,if%20the%20medicines%20are%20working on December 23, 2022. 17CMS included HIV viral suppression in its 2023/2024 core set of adult health care quality measures for Medicaid. This list includes measures to assess and improve health care quality. Medicaid, 2023 and 2024 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set). Accessed at https://www.medicaid.gov/medicaid/quality-of-care/downloads/2023- adult-core-set.pdf on February 8, 2023. Also, for the purpose of the core measures, see CMS, Core Measures. Accessed at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures on February 8, 2023. 18 CMS, "Monitoring and Improving Viral Load Suppression Among PLWH," Opportunities to Improve HIV Prevention and Care Delivery to Medicaid and CHIP Beneficiaries, December 1, 2016. See page 13. Download document at at https://www.hhs.gov/guidance/document/opportunities-improve-hiv-prevention-and-care-delivery-medicaid-and-chip- beneficiaries on February 9, 2023. 19 CDC, "Importance of Complete Laboratory Reporting" and "How Selected National HIV Care Outcomes are used to Monitor Progress and Identify Needs," Selected National HIV Prevention and Care Outcomes in the United States, July 2019. Accessed at https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-national-hiv-care-outcomes.pdf on December 23, 2022. 20 An estimated 34 percent of people diagnosed with HIV are not virally suppressed due to poor adherence to the continuum of care and to ART. See "Introduction" on page 387/L-2 of HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, 2022. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent- arv/guidelines-adult-adolescent-arv.pdf on May 3, 2023. 21NIH, 10 Things to Know About HIV Suppression, June 12, 2020. Accessed at https://www.niaid.nih.gov/diseases- conditions/10-things-know-about-hiv-suppression on December 23, 2022. 22 CMS, Medicare and Other Health Benefits: Your Guide to Who Pays First, 2021. See pages 6 and 11. Accessed at https://www.medicare.gov/sites/default/files/2021-10/02179-Medicare-and-other-health-benefits-your-guide-to-who-pays- first.pdf on June 16, 2023. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Endnotes | 22 23 The Commonwealth Fund, How Differences in Medicaid, Medicare, and Commercial Health Insurance Payment Rates Impact Access, Health Equity, and Cost, August 17, 2022. Accessed at https://www.commonwealthfund.org/blog/2022/how- differences-medicaid-medicare-and-commercial-health-insurance-payment-rates-impact%20 on February 9, 2023. 24MACPAC, Physician Acceptance of New Medicaid Patients. See slides 6-7. Accessed at http://www.macpac.gov/wp- content/uploads/2019/01/Physician-Acceptance-of-New-Medicaid-Patients.pdf on January 25, 2023. 25KFF, "Medicare Eligibility for People with HIV," Medicare and People with HIV, 2023. See details under Impact on People with HIV for the Individuals age 65 and older category in Table 1. Accessed at https://www.kff.org/hivaids/fact-sheet/medicare- and-hiv/ on January 26, 2023. 26OIG, "CMS-Medicaid," OIG's Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs, 2022. See #12 of Top Unimplemented Recommendations, document pages 20-21. Accessed at https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2022.pdf on February 6, 2023. 27 OIG, "5: Harnessing and Protecting Data and Technology To Improve the Health and Well-Being of Individuals," Top Management and Performance Challenges Facing HHS, 2022. See "Improving access to HHS data," second paragraph, document page 32. Accessed at https://oig.hhs.gov/reports-and-publications/top-challenges/2022/2022-tmc.pdf on February 6, 2023. 28 KFF, 10 Things to Know About Medicaid, June 2023. See sections 2, 4, 5, 6, and 7 for details on ways in which Medicaid programs vary. Accessed at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts- straight/ on February 6, 2023. 29CMS, January 2023 Medicaid and CHIP Enrollment Trends Snapshot. Accessed at https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/january-2023-medicaid-chip- enrollment-trend-snapshot.pdf on May 3, 2023. CMS, NCH and MEDPAR Data Dictionary, 2022. Accessed at https://www.cms.gov/research-statistics-data-systems/nch-and- 30 medpar-data-dictionary on February 9, 2023. 31Chronic Conditions Data Warehouse, CCW Medicare Encounter Data File User Guide. Accessed at https://www2.ccwdata.org/web/guest/user-documentation on February 9, 2023. 32CMS, "What are Prescription Drug Event (PDE) data?," Questions and Answers on Obtaining Prescription Drug Event (PDE) Data. Accessed at https://www.cms.gov/medicare/prescription-drug- coverage/prescriptiondrugcovgenin/downloads/partdclaimsdataqa.pdf on February 9, 2023. ASPE, "Enrollment DataBase," Centers for Medicare and Medicaid Services. Accessed at https://aspe.hhs.gov/centers- 33 medicare-medicaid-services on February 9, 2023. 34 We did not assess whether values populated in States' claims data were valid procedure or NDC codes. 35 We referenced CMS's thresholds for high concern and unusable State assessments for National Drug Code – RX, Procedure Codes – OT Professional, and Procedure Codes – OT Institutional. See these topics accessed at https://www.medicaid.gov/dq- atlas/landing/topics/info on March 13, 2023. 36 CMS, Medicare and Other Health Benefits: Your Guide to Who Pays First, 2021. See pages 6 and 11. Accessed at https://www.medicare.gov/sites/default/files/2021-10/02179-Medicare-and-other-health-benefits-your-guide-to-who-pays- first.pdf on June 16, 2023. 37 Chronic Conditions Data Warehouse, "Human Immunodeficiency Virus and/or Acquired Immunodeficiency Syndrome (HIV/AIDS)," Other Chronic Health, Mental Health, and Potentially Disabling Conditions Algorithms, 2022. Accessed by downloading HIV/AIDS PDF from https://www2.ccwdata.org/web/guest/condition-categories-other on February 9, 2023. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Endnotes | 23 38HHS, "Initiation of Antiretroviral Therapy," Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Accessed at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/initiation-antiretroviral-therapy?view=full on May 10, 2022. 39Families First Coronavirus Response Act, H.R. 6201, 116th Congress. § 6008(b)(3)(2020). Accessed at https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf on February 9, 2023. 40HRSA, Performance Measure Portfolio, 2022. See "Core Measures" PDF. Accessed at https://ryanwhite.hrsa.gov/grants/performance-measure-portfolio on February 6, 2023. 41 Tukey, John W., Exploratory Data Analysis, Vol. 2, 1977. 42HHS recommends initiating ART immediately or as soon as possible. In limited cases, such as those of people with HIV who have cryptococcal and TB meningitis, HHS notes that a short delay before initiating ART may be warranted. See "Concerns regarding immune reconstitution inflammatory syndrome (IRIS)" under Antiretroviral Therapy for Persons with Acute Opportunistic Infections and Malignancies. Accessed at https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult- and-adolescent-arv/initiation-antiretroviral-therapy on January 9, 2023. 43HHS, "Clinic or Laboratory Monitoring Visits Related to HIV Care," Guidance for COVID-19 and People with HIV, 2021. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/archive/covid-19-hiv-2021-02-26.pdf on October 13, 2022. 44 HHS, Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV, see page 389/L-4, second paragraph under "Improving Retention in Care," for more information about use of telehealth for HIV care during the COVID-19 public health emergency. Accessed at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent- arv/guidelines-adult-adolescent-arv.pdf on January 4, 2023. 45ResDAC, CMS Cell Size Suppression Policy, 2017. Accessed at https://resdac.org/articles/cms-cell-size-suppression-policy on February 6, 2023. 46ResDAC, CMS Cell Size Suppression Policy, 2017. Accessed at https://resdac.org/articles/cms-cell-size-suppression-policy on February 6, 2023. Data Brief: One Quarter of Medicaid Enrollees with HIV May Not Have Received Critical Services in 2021 OEI-05-22-00240 Endnotes | 24