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The Affordable Care Act and Ryan White

Where are we heading?

What Will the ACA Mean for Addressing the HIV Epidemic?

Colorado Cascade of Care


16000 14000 Number of Individuals 12000 10000 8000 6000 4000 2000 0 HIV Infected Diagnosed Linked to Care Retained in Care Virally Suppressed
82%

14,266 11,698

5,755
49%

4,875 3,728
42% 32%

From CDPHE Surveillance Program

Helping People Move Through the Cascade


Achieve Viral Suppression Retained in Care Linked to Care First Diagnosis with HIV

The Process is NOT Linear


Linked to Care First Diagnosis with HIV Retained in Care

Re-Engaged

Achieved Viral Suppression

Lapsed in Care

The post-ACA approach to HIV care:


n Focus on services that are proven to help people move through

the cascade toward viral suppression

n If a person is eligible for Medicaid, Medicare, or commercial

insurance, the Ryan Program is required to vigorously pursue enrollment of the person in these types of coverage
n If there is a service that would help move people through the

cascade but cannot be funded from a third party payer, Ryan White funding can be used to pay for that service. achievement of viral suppression, not just the long-standing Ryan White system.

n Monitor how well the enIre system of care is assisIng with

A new way to triage clients


What would help this client move through the care cascade?
Eligible for 3rd party payment?

NO

YES
Service is reasonably accessible?

NO

YES

UIlize Ryan White funding to provide the service

Provide the service and bill the 3rd party payer or refer to a provider who can do so

Services
HIV Testing Outreach Linkage Referral Retention Ambulatory care Case management Transportation Adherence Oral health Financial Assist ADAP Housing Nutrition/Food Psychosocial HE/RR Mental health tx Substance use tx

Diagnosed

Linked

Retained

Viral Supp

Re-engage

Eligibility for 3rd Party Payment


n

Both the CLIENT and the SERVICE NEEDED must be evaluated for potenIal 3rd party payment Eligibility criteria: Residence, ciIzenship, income level, household size Payers: Medicaid, Medicare, Plans through the Marketplace, Employer Based Plans Services they will pay for: the EssenIal Health Services (as interpreted by the payer) If the client is ELIGIBLE but not ENROLLED must vigorously pursue enrollment.

n n

+ Mapping Client Transitions


Uninsured Lawfully present Income up to 138% FPL Uninsured Lawfully present Income 138 - 400% FPL Currently on Medicaid Currently on other government-sponsored insurance (e.g., Medicare, TRICARE) Currently on or have access to employerbased coverage Currently on PCIP or high risk pool Uninsured and categorically ineligible for federal programs Medicaid

Subsidized private insurance through Marketplace No transition No transition If plan is affordable and comprehensive, no transition Medicaid or Marketplace coverage No transition

HRSA Policy Notice13-01: Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services
n Grantees and their subgrantees are expected to:
n Vigorously pursue Medicaid enrollment for individuals who are

likely eligible for coverage, n Seek payment from Medicaid when they provide a Medicaid- covered service for Medicaid beneciaries n Back-bill Medicaid for RWHAP-funded services provided for all Medicaid-eligible clients upon determinaIon.

HRSA Policy Notice13-03: Eligibility Post-Affordable Care Act


n Recommends grantees align program nancial eligibility

determinaIons with those for new coverage opIons, mainly modied adjusted gross income (MAGI) Marketplace eligibility and enrollment processes to reduce burden and increase coordinaIon Medicaid and/or Marketplace noIce of eligibility determinaIon when applying for or being recerIed for RWHAP

n Recommends grantees align client recerIcaIon processes with

n Grantees may consider requiring that clients provide their

HRSA Policy Notice13-04: Eligibility for Private Health Insurance and Coverage by RWHAP
n Reiterates that RWHAP grantees must make every eort to ensure

that eligible uninsured clients expediIously enroll in private health insurance when possible; this requirement will be monitored

n Grantees need to inform clients of the penalty for not enrolling n Clients who receive a cerIcate of exempIon from the Internal

Revenue Service (IRS) may conInue to receive RWHAP services

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HRSA Policy Notice13-04 (continued)
n Open enrollment into private health plans is for a limited

Ime during the year

If the client misses the open enrollment period, the grantee must make every eort to ensure the client enrolls in the next open enrollment period

n Grantees must maintain policies regarding the required

process for pursuing enrollment for all clients, documentaIon of steps to pursue enrollment, and establishment of monitoring and enforcement of sub- grantee processes to ensure enrollment

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HRSA Policy Notice13-04 (continued)

n RWHAP funds generally may NOT be used to pay for services

outside of their insurance network unless services are not available from an in-network provider
n RWHAP funds may be used to pay for higher co-pays and

deducIbles within Iered networks but must consider availability of resources prior to making such allocaIons

Reasonably accessible
n The service is consistent with the HIV Care and Treatment

Program Standards of Care; n The service is available to the client within sixty calendar days or more promptly if needed to prevent death or substanIal, irreversible harm to the client; and, n The service is located within 70 miles of the client residence. n This is CDPHEs interpretaIon of HRSA rules and is subject to HRSA revision. Other Colorado HRSA Grantees (Part A, C, D) may have dierent interpretaIons.

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RX

Colorado Service Cross Walk


SERVICE Qualified Health Plans MEDICAID RW / ADAP Cost-sharing assistance

MEDICAL CASE MANAGEMENT ORAL HEALTH LABS MENTAL HEALTH SERVICES SUBSTANCE ABUSE TREATMENT HIV PRIMARY CARE MEDICAL TRANSPORTATION INPATIENT HOSPITAL SERVICES

X X

X
Limited Coverage Cost-sharing assistance Cost-sharing assistance Cost-sharing assistance Cost-sharing assistance

Limited Coverage

HRSA Policy Notice13-01: Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services
n Once an individual is enrolled in Medicaid, RWHAP funds may

be used to pay for: n Any medically necessary services which Medicaid does not cover or where Medicaid coverage is limited in scope n Premiums, co-pays and deducIbles if required n Other core medical services as a part of primary care if those services are not covered or are limited under Medicaid, even when those services are provided at the same visit as Medicaid covered services.

HRSA Policy Notice13-04: Eligibility for Private Health Insurance and Coverage by RWHAP
n RWHAP funds may be used to pay for services received

during the Ime between which a client enrolls in third party coverage and it becomes eecIve

n Once enrolled in a private health plan, RWHAP funds may

only be used for services not covered or parIally covered by a clients plan

What are some other implicaIons of the Aordable Care Act for People Living with HIV or AIDS?

Pre-ACA Scenario for HIV negative people


n HIV

and STIs are highly concentrated among the poor and the uninsured. cost STI care for the uninsured is very limited in terms of geography and provider mental health or substance use issues are driving HIV risk, low cost counseling is also very limited health care providers are identifying most new HIV cases, but there is still a fear of becoming uninsurable due to HIV testing (even if negative)

n Low n If

n Private

Post-ACA Scenario for HIV negative people


nMost

HIV negative people will be eligible for Medicaid or some other form of coverage. they enroll, they should have new coverage that should reduce their vulnerability for HIV:
n STI

nIf

screening and treatment n HIV testing n Mental health care n Substance abuse treatment

Hopeful results from Massachusecs, the pioneer in universal health coverage

Enormous IMPACT of HEALTH REFORM on PLWH/A in Massachusetts

IN MEDICAL CARE
US 41% MA 99%

TAKING HIV MEDICATIONS


US 36% MA 90%

Viral Load Suppressed


US 28% MA 72%

DIAGNOSIS & DEATHS


nWhile

HIV Diagnoses increased by 2% nationally between 2006 and 2009, there was a 25% DECREASE in HIV Diagnoses in Massachusetts. there was a significant decrease in HIV Deaths during this period (33%), Massachusetts beat this figure as well 44%)

nWhile

But the changes in Massachusecs were also very dramaIc for service providers

Specialty STD clinics scaled back


nRegional

STD clinic closures were completed in June 2009. clinics maintained services, including a free clinic and a fee-for-service clinic. Clinic hours were reduced hours services were transferred to private doctor offices and clinics

nFour

nSTD

Preliminary Lessons Learned in Massachusetts


n Access Care n Benets of reform are not uniform n Medical providers may not have capaciIes to address eligible

paIent care needs n Some public costs cannot be shieed in a health reform environment n Training needs for clinical providers may be signicant as specialized public health funcIons are pushed into primary care venues. n Establish baseline and future data needs, and variables to track impact

WHAT IS NEXT?

Next steps . . .
Providers of services for PLWH/A should adopt the new triage approach to their clients and the service provided Every provider should build their capacity to screen for eligibility and vigorously pursue enrollment Providers are WELL ADVISED to build their capacity to bill Medicaid or other 3rd party payers for at least some of the services they provide Current Ryan White funded services will need to be parsed between those that are reasonably accessible through a 3rd party payer and those that are not.

Next steps . . .
Ryan White will con>nue to be important source of care and services for many people with HIV or AIDS
Most Ryan White clients will have coverage but sIll need the program to complete their care, ll in gaps, help with costs. Ryan White provides important HIV-related services that are not always provided by insurance plans Those who are undocumented are not eligible for Medicaid or marketplaces; Legal residents have 5 year waiIng period for Medicaid