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BACKGROUND People with schizophrenia experience unique barriers to routine HIV testing, despite increased risk of HIV compared to the general US population. Little is known about how healthcare delivery system factors impact testing rates or whether there are testing differences for people with schizophrenia. SETTING Nationally representative sample of Medicaid enrollees with and without schizophrenia. METHODS Using retrospective longitudinal data, we examined whether state-level factors were associated with differences in HIV testing among Medicaid enrollees with schizophrenia compared to frequency matched controls during 2002-2012. Multivariable logistic regression estimated testing rate differences between and within cohorts. RESULTS Higher HIV testing rates for enrollees with schizophrenia was associated with higher state-level Medicaid spending per enrollee, efforts to reduce Medicaid fragmentation, and higher federal prevention funding. State-level AIDS epidemiology predicted more frequent HIV testing for enrollees with schizophrenia versus controls. Living in rural settings predicted lower HIV testing, especially for people with schizophrenia. CONCLUSION Overall, state-level predictors of HIV testing rates varied among Medicaid enrollees, though rates were generally higher for those with schizophrenia than controls. Increased HIV testing for people with schizophrenia was associated with coverage of HIV testing when medically necessary, higher CDC prevention funding, and higher AIDS incidence, prevalence, and mortality when compared to controls. This analysis suggests that state policymaking has an important role to play in advancing that effort. Overcoming fragmented care systems, sustaining robust prevention funding, and consolidating funding streams in innovative and flexible ways to support more comprehensive systems of care delivery deserve attention.