CMS HIV Screening Coverage Policy Updated: What Billing Teams Need to Know (NCD 335)

The Centers for Medicare & Medicaid Services has modified its National Coverage Determination for HIV screening (NCD 335), with an updated policy effective March 12, 2026. This change affects how Medicare covers HIV screening tests for beneficiaries across multiple age groups and risk categories — and if your practice serves adolescents, adults under 65, older high-risk patients, or pregnant women, your billing team needs to understand exactly who qualifies and under what conditions.

CMS HIV Screening Coverage Under Medicare: What NCD 335 Actually Covers

The Centers for Medicare & Medicaid Services first began covering HIV screening on December 8, 2009, using its authority under 42 C.F.R. §410.64 to add "additional preventive services" when the United States Preventive Services Task Force (USPSTF) assigns a Grade A or Grade B recommendation. HIV screening carries a Grade A USPSTF recommendation for three populations, and CMS's coverage follows that framework directly.

For claims with dates of service on and after April 13, 2015 (the existing coverage baseline now being modified under the March 2026 update), CMS has determined that screening is reasonable and necessary for early detection of HIV. The benefit sits under the Additional Preventive Services benefit category and is available to beneficiaries entitled to Part A or enrolled under Part B.

The covered tests must be FDA-approved laboratory tests or point-of-care tests, used consistent with FDA-approved labeling, and performed in compliance with Clinical Laboratory Improvement Act (CLIA) regulations.

Who Qualifies for Medicare-Covered HIV Screening Under NCD 335

Coverage breaks down into three distinct patient populations. Understanding which bucket a patient falls into determines both coverage eligibility and documentation requirements.

Population 1: Standard-Age Beneficiaries (Ages 15–65)
CMS covers a maximum of one annual, voluntary HIV screening for all adolescents and adults between the ages of 15 and 65 — without regard to perceived risk. No risk documentation is required for this group. The test must be ordered by the beneficiary's physician or practitioner within the context of a healthcare setting and performed by an eligible Medicare provider.

Population 2: Outside the Standard Age Band, at Increased Risk
For adolescents younger than 15 and adults older than 65, coverage requires that the beneficiary be at increased risk for HIV infection. CMS defines increased risk to include:

• Men who have sex with men
• Men and women having unprotected vaginal or anal intercourse
• Past or present injection drug users
• Men and women who exchange sex for money or drugs, or have sex partners who do
• Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users
• Persons who have acquired or request testing for other sexually transmitted infectious diseases
• Persons with a history of blood transfusions between 1978 and 1985
• Persons who request an HIV test despite reporting no individual risk factors
• Persons with new sexual partners
• Persons who, based on individualized physician interview and examination, are deemed to be at increased risk — as determined by the treating practitioner

That last criterion matters significantly for billing. The ordering practitioner's documented clinical assessment can establish increased risk even when a patient doesn't fall neatly into any of the categories above. This assessment needs to be in the medical record before the claim goes out.

Population 3: Pregnant Beneficiaries
The USPSTF Grade A recommendation extends to all pregnant women, and CMS coverage follows. Pregnant Medicare beneficiaries are addressed separately within the policy. Billing teams serving OB/GYN practices or maternal-fetal medicine should confirm that pregnancy documentation is present in the record to support claims for this group.

Prior Authorization and Ordering Requirements for CMS HIV Screening

NCD 335 does not specify a prior authorization requirement for covered HIV screening services. However, coverage is contingent on the screening being ordered by the beneficiary's physician or practitioner within the context of a healthcare setting. Screening tests performed outside that context — or without a documented order — may not meet coverage criteria.

The voluntary nature of the screening is also embedded in the policy language. The test must be voluntary, which in practice means the patient's agreement to be screened should be documentable if a claim is ever audited.

Affected Codes

The current version of NCD 335 (policy key 335-v2) does not list specific CPT or HCPCS codes within the policy data. CMS does not enumerate billing codes directly within this NCD.

For the correct laboratory and point-of-care test codes applicable to HIV screening under Medicare, billing teams should cross-reference the Medicare Claims Processing Manual and your MAC's local guidance. Common coding resources for HIV screening include the CMS HIV screening FAQ documents and applicable Local Coverage Determinations from your MAC.

Related ICD-10 Diagnosis Codes used to support medical necessity for HIV screening — particularly for the increased-risk populations outside the 15–65 age band — may include encounter codes for HIV screening, exposure to HIV, and high-risk sexual behavior. Work with your coding team to confirm the most current applicable diagnosis codes per your MAC's guidance, as these are not enumerated in the NCD itself.

What Your Billing Team Should Do