Section 1: Program Description

The HIV Primary Care Medicaid Program was established in 1989 by the New York State Department of Health to ensure early diagnosis and access to care for persons with HIV infection. The program is central to the Department's strategy for integrating HIV testing into routine medical care in a variety of settings and for ensuring that persons with HIV have access to appropriate therapeutic and prophylactic interventions.


Eligibility is limited to health facilities (hospitals and diagnostic and treatment centers), which are:

  1. licensed under Article 28 of the Public Health Law;
  2. approved to participate in the New York State Medicaid Program, and
  3. have signed an agreement with the New York State Department of Health to provide comprehensive services and coordination of care for persons with HIV.

The Agreement for HIV Primary Care Medicaid Program has been revised to reflect program changes effective November 1, 2006. All facilities currently enrolled in the program must sign a new agreement (see Section 2) and return it to the New York State Department of Health by January 1, 2007.

Reimbursement Rates and Billing Instructions

HIV Primary Care reimbursement rates vary depending on the visit type and geographic area. These rates are all-inclusive and cover labor, ancillary, capital and administrative costs. See Section 3 for billing instructions, medical record documentation requirements and utilization limits.

Visit Descriptions

As of November 1, 2006, the program includes reimbursement for the five outpatient visits described in this section. A brief list of tools and resources for the five visits is included at the end of this section. Comprehensive listings may be found in Sections 6 and 7 of this Memorandum.

HIV Testing Visit

HIV Testing is performed to determine the HIV status of the patient and to link him/her with prevention and care services.HIV testing must adhere to the requirements of Article 27-F of the Public Health Law as interpreted in the New York State Department of Health's 2005 Guidance.

The 2005 Guidance calls on health care providers to discuss and offer voluntary HIV testing at least once in the course of routine health care for all adult patients. HIV testing should be presented as a clinical recommendation:

  • In all high seroprevalence areas, including all major urban areas of the state;
  • In all health settings serving people at risk of HIV infection, and
  • To all patients who indicate risk.

Since many patients may not be comfortable disclosing risk, providers should adopt a low threshold for recommending testing.

Each year in New York State, a number of pregnant women become infected subsequent to HIV testing early in pregnancy. Third trimester testing is recommended to identify these women; however, at any time during the pregnancy, immediate testing should be recommended to all women with signs and symptoms suggestive of acute HIV infection.

The 2005 Guidance removes barriers to integrating HIV testing into routine health care by promoting a streamlined approach to pre-test counseling and the use of a simplified Informed Consent to HIV Testing form. A nurse or other member of the health care team may present the informed consent form to the patient to review before the clinician enters the exam room. Pre-test counseling can be as simple as explaining to the patient that the health facility routinely encourages patients to the HIV test, asking if he/she has any questions about the information on the consent form, obtaining the patient's signature on informed consent form and placing it in the patient's medical record. If a patient has questions or concerns, the physician or other staff may provide tailored counseling to meet his or her unique needs.

The Department encourages the use of

  • HIV antibody and viral load testing should be strongly recommended to patients with risk factors for HIV, who present with symptoms suggestive of acute HIV infection (AHI) or with sexually transmitted infections (STIs).Viral load testing is indicated since a person with AHI may not yet have antibodies but will have a high level of virus in plasma. Since AHI has emerged as a major factor in mother-to-child HIV transmission, providers should adopt a low threshold for recommending viral load testing to pregnant women with flu-like symptoms, who may not be aware of their risk.

Patients who test negative should be informed of the test result and given the Department's brochure, Information on Negative HIV Test Results. If the patient has engaged in recent risk behavior but does not have symptoms of AHI, retesting should be recommended three months after the most recent exposure.

HIV Counseling without Testing Visit

The HIV Counseling without Testing visit is appropriately billed when the patient declines testing after the clinician or other member of the health care team reviews the information in the Informed Consent to Perform HIV Testing form, answers the patient's questions, and encourages him/her to test. This visit may also be billed when the provider administering the test determines the patient lacks the capacity to consent or to complete the testing process.

HIV Counseling Visit (Positive)

The goals of post-test counseling for individuals with an initial positive test result are:

  • To deliver the test result (preliminary or confirmed positive);
  • To help the patient cope with the emotional consequences of learning the test result;
  • To explain the benefits of treatment and ensure that the patient enters medical care either on site or by referral;
  • To provide partner counseling and assistance per New York State Department of Health Guidelines, and
  • To provide risk reduction counseling to prevent further HIV transmission.

Several visits may be necessary to achieve these goals for newly diagnosed individuals.

For persons with established HIV diagnoses, prevention/risk-reduction counseling and partner counseling and assistance are ongoing processes which should be provided as part of comprehensive care. Both New York State Department of Health and Centers for Disease Control Guidelines recommend that prevention messages and brief patient-centered interventions be integrated into each clinical visit. A more comprehensive risk reduction and partner counseling visit is indicated annually; therefore, the HIV Counseling (Positive) visit may be billed annually for persons with HIV in clinical care.

New York State licensed physicians and other persons authorized to order diagnostic tests are required by Public Health Law (Article 21, Title III) to report all newly diagnosed cases of HIV infection and AIDS. See Tools and References at the end of this Section.


  • As of November 1, 2006, hospital EDs may bill the HIV Testing Visit and the HIV Counseling (Positive) Visit as appropriate. EDs may bill the HIV Testing Visit only when using rapid HIV tests, which provide results within a single visit. The costs of the rapid test kit and controls are included in the visit rate. The ED must provide HIV counseling and linkage to confirmatory testing and medical services when an ED patient's rapid HIV test result is a preliminary positive.
  • See Section 3 for billing instructions, including same-day billing of HIV testing visits and ED visits.
    See Section 5 for answers to frequently asked questions about HIV testing in EDs.

Initial/Annual Comprehensive HIV Medical Evaluation

The goals of the Initial/Annual Comprehensive HIV Medical Evaluation are to stage the disease for prognostic and treatment purposes, identify active HIV-related opportunistic infections and tumors, identify medical conditions associated with the person's HIV risk activity, identify psychosocial problems and needs, develop strategies to prevent disease progression, and identify non-HIV related health care needs.

HIV Monitoring

New York State Department of Health guidelines recommend HIV monitoring at baseline and every four months thereafter for patients on antiretroviral therapy. Monitoring consists of an interim medical evaluation and immunologic and virologic assessments when indicated based on current guidelines.

Compliance with Department of Health Rules and Regulations (Title 10 NYCRR)

Facilities participating in the HIV Primary Care Medicaid Program must comply with all requirements set forth in New York State Department of Health Rules and Regulations (Title 10). Given the demographic profile of the HIV epidemic in New York, it is critically important that facilities provide culturally competent HIV services and address communications barriers by providing skilled interpreters for non-English speaking groups and for persons with vision and hearing impairments.

Tools and References for HIV Primary Care Medicaid Program Visits

HIV Testing

Reporting and Partner Notification

HIV Clinical Guidelines

Testing for Acute HIV Infection (AHI) - Providers outside New York City

  • New York State Department of Health
    Wadsworth Center, Diagnostic HIV Laboratory
    (518) 474-2163

Testing for Acute HIV Infection (AHI) - New York City Providers

  • New York City Department of Health & Mental Hygiene
    HIV Surveillance and Epidemiology Program
    Provider Line: (212) 442-3388