Does Medicare Cover HIV Screenings?
Medicare Part B medical insurance covers annual HIV screenings if you meet certain conditions. You have to be enrolled in Medicare Part B and either ask to be tested, be at an increased risk for contracting the human immunodeficiency virus or a pregnant woman.
Does Medicare Pay for HIV Screening?
Medicare Part B medical insurance will cover 100 percent of the Medicare-approved costs of one voluntary HIV screening test per year if you meet certain conditions. It will pay for up to three HIV tests per year for pregnant Medicare recipients.
If you meet the requirements, you pay no deductible, copayments or coinsurance for the screening. Medicare Advantage plans are also required to cover all these out-of-pocket costs so long as you meet these requirements and receive the HIV screening from one of your plan’s in-network health care providers.
The HIV screening must be done with tests approved by the U.S. Food and Drug Administration and ordered by your doctor or other qualified health care provider.
The health care professional administering the test and the supplier of the FDA-approved testing materials must also be eligible Medicare providers before Medicare will pay for the HIV screening.
Who Is Covered for Medicare HIV Screenings?
Medicare covers HIV tests for beneficiaries who meet certain requirements.
You can receive one voluntary HIV screening per year if you are a Medicare beneficiary between the ages of 15 and 65, regardless of your risk for getting HIV.
If you are enrolled in Medicare and younger than 15, older than 65 or pregnant, you can receive one voluntary test per year if you are in a high-risk group for getting the virus.
- Anyone with a new sexual partner.
- Men and women having unprotected vaginal or anal sex.
- Men who have sex for money or drugs or have partners who do.
- Men who have sex with men.
- Past or present use of injectable illicit drugs.
- People who a doctor determines is at increased risk for HIV infection from a Medicare annual wellness review.
- People who had a blood transfusion between 1978 and 1985.
- People who have requested an HIV test but reported no individual risk factors.
- People who have requested or had previous tests for other sexually transmitted diseases.
- People whose past or present partners were HIV-positive, bisexual or injected drug users.
If you are a pregnant Medicare beneficiary, you can receive a maximum of three voluntary HIV screenings at key points during your pregnancy regardless of your level of risk for contracting the virus.
- When the pregnancy is diagnosed
- During the third trimester of pregnancy
- At labor, if ordered by the woman’s doctor
HIV can be transmitted by sexual contact, through blood or blood products, and by infected mothers to their fetus during pregnancy or their infants at birth or through breast milk.
The Medicare guidelines were established to cover a wide range of possible risk factors even though many of the beneficiaries — such as pregnant women or those under the age of 65 – constitute a small percentage of overall Medicare beneficiaries.
What Do HIV Screening Tests Involve?
There are three types of tests used in HIV screenings. Each is performed on blood or fluid taken from your mouth.
- Nucleic Acid Tests
- A NAT requires blood drawn from your vein. A laboratory examines the viral load — or how much of the virus — that’s present in your blood. The test can detect HIV earlier than other tests but is very expensive and seldom used unless you've very recently had a high-risk exposure or are showing HIV symptoms. Results can take several days to get back from the laboratory.
- Antigen/Antibody Test
- These tests also look for antibodies or antigens in your blood that indicate you’ve been exposed to HIV. Your immune system produces antibodies after you’ve been exposed to the virus. Antigens are foreign substances that can also activate your immune system if you’ve been exposed. HIV produces a specific antigen — p24 — even before your immune system produces antibodies. These tests can be done with blood drawn from a vein or from a finger prick and are widely used in the U.S. Results can be available in 30 minutes or less.
- Antibody Tests
- Antibody tests look solely for antibodies your immune system has produced in response to HIV. These tests may look at your blood or oral fluid, but testing your blood usually detects the virus sooner. Most rapid tests and the only FDA-approved self-test for HIV fall into this type. Results can be available in 30 minutes or less for the rapid screening test on blood, or within 20 minutes for the oral fluid test.
It can take anywhere from 10 days to 90 days after you’ve been exposed to HIV before a test can detect it in your system. The time varies from person-to-person and also based on what type of test is used.
The time between exposure to HIV and when a test can detect it is called the “window period.”
This period tells you the earliest and the latest time it takes before the virus shows up in different types of tests. This is effectively the earliest and the latest that you may test positive for HIV.
|HIV Test Type||Window Period|
|NAT (nucleic acid test)||10 to 33 days|
|Antigen/antibody test||18 to 45 days (drawn blood)|
18 to 90 days (finger prick)
|Antibody test||23 to 90 days|
If you get a negative test result from an HIV screening, it’s important to wait until after your test’s window period closes to be tested again.
5 Cited Research Articles
- U.S. Centers for Disease Control and Prevention. (2020, October 20). What Kinds of Tests Are Available, and How Do They Work? Retrieved from https://www.cdc.gov/hiv/basics/hiv-testing/test-types.html
- U.S. Centers for Medicare & Medicaid Services. (2020, June 27). HIV Prevention is Important – Medicare Covers Testing. Retrieved from https://www.medicare.gov/blog/hiv-prevention-and-testing-2020
- U.S. Centers for Medicare & Medicaid Services. (2019, June 27). The Time Is Now, Get Tested for HIV. Retrieved from https://www.medicare.gov/blog/the-time-is-now-get-tested-for-hiv
- U.S. Centers for Medicare & Medicaid Services. (2015, April 13). Decision Memo for Screening for the Human Immunodeficiency Virus (HIV) Infection (CAG-00409R). Retrieved from https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=276
- U.S. Centers for Medicare & Medicaid Services. (n.d.). HIV Screenings. Retrieved from https://www.medicare.gov/coverage/hiv-screenings