Table 1. Special AIDS Capitation Rates in State Medicaid Programs.
| Program and Region or State | Waiver Authority | Eligibility Criteria | Protease Inhibitors | Viral-Load Testing | Other | Capitation Rate(s)1 |
|---|---|---|---|---|---|---|
| AIDS Healthcare Foundation, Los Angeles | 1915(b) Voluntary | 1993 CDC AIDS Definition | Excluded | Included | Excludes | 2 $1,139 Inpatient Care |
| California Two-Plan Counties 3 | 1915(b) Voluntary | 1993 CDC AIDS Definition | Varies | Included | — | $1,000-1,070 |
| CalOPTIMA, Orange County, California | 1915(b) Mandatory | 1993 CDC AIDS Definition | Excluded | Included | Excludes Mental Health, Dental, SNF, and Pharmacy | 4 $1,722 |
| HealthChoice, Maryland | 1115 Mandatory | 1993 CDC AIDS Definition | Excluded | Excluded | Excludes Children | 5 $2,161 Baltimore, $1,812 Elsewhere |
| Massachusetts | 1915(b) Voluntary | 6HIV+ Test, CD4 Count Less Than 200 or Percentage Below 14, Treatment Within Past 12 Months for Active or Advanced AIDS | Excluded | Included | — | $2,300 Active AIDS, $2,988 Advanced AIDS |
| Enhanced Capitation Rate, New York State | 1115 Mandatory (Planned) | 7CD4 Count Less Than 200, Certain ICD-9 Codes, State AIDS Registry Certification | Excluded | Included | — | 8 Increase Based on AIDS Enrollment |
| Special Needs Plan, New York State | 91115 Voluntary (Planned) | HIV or AIDS and Uninfected Family Members to Age 19 | Excluded | Included | — | To Be Determined |
| Accessing Better Care, Ohio | Pilot Program | 1993 CDC AIDS Definition | Included | Included | 10 2 counties | 11 Variable |
| Salt Lake County, Utah | Voluntary | 1993 CDC AIDS Definition | Excluded | Included | — | $1,198 Plus Eligibility Category Rate |
Per member per month, paid by the State.
Inpatient care is capitated at an additional $657 per person per month. This expected inpatient hospitalization amount is placed in a risk pool, and any savings from the pool are divided between the State and the AIDS Healthcare Foundation.
Enrollees may choose between a public and a commercial plan.
This is the rate paid for AIDS patients to participating MCOs by CalOPTIMA, but CalOPTIMA does not receive this amount from the State.
For the program's second year, which began July 1998, rates have been cut 25 percent, and the State is exploring adopting an HIV capitation rate.
See Technical Note for lists of ICD-9 codes corresponding to definitions of active and advanced AIDS.
See Technical Note for list of AIDS-defining ICD-9 codes.
See Table 6.
To be voluntary for the first 2 years of the program, then mandatory.
Columbus and Cincinnati; Cleveland was also in the program originally but dropped out.
There are 7 payment categories geared to prior year's expenditures for enrollee.
NOTES: AIDS is acquired immunodeficiency syndrome. CDC is Centers for Disease Control and Prevention. SNF is skilled nursing facility. HIV is human immunodeficiency virus. ICD-9 is the International Classification of Diseases, 9th Revision. MCO is managed care organization.
SOURCE: Conviser, R., Health Resources and Services Administration, Rockville, MD, 1998.