Updates from the

ADAP and from the

State Health
Department

Todd Grove
Colorado Department of Public
Health & Environment
AIDS Drug Assistance Program

Colorado Cascade of Care

16000
14,266

Number of Individuals

14000
11,698

12000
10000
8000

82%

5,755

6000

4,875
3,728

49%

4000

42%

2000

32%

0
HIV Infected

From CDPHE Surveillance Program

Diagnosed

Linked to Care Retained in

Care

Virally
Suppressed

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
Retained
in Care

First
Diagnosis
with HIV

Re-Engaged

Achieved Viral
Suppression

Lapsed in Care

The post-ACA approach to HIV care:

Focus on services that are proven to help people move through

the cascade toward viral suppression

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

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.

Monitor how well the entire system of care is assisting with

achievement of viral suppression, not just the long-standing
Ryan White system.

FEDERAL HIV AIDS RESOURCES

Health Resource Services Administration
HIV/AIDS Bureau (HRSA- HAB)
Ryan White Treatment Extension Act of 2009
RYAN WHITE CARE ACT

PART A

PART B

PART C

EMAs -TGAs

States and Territories

Denver Mayor's
Office of HIV Resources

ADAP & Base Funding

State of CO -CDPHE

Infectious Disease Clinics

Beacon, Denver,
Pueblo Comm., St. Mary's

PARTS D-F
WICY-DENTAL
SPNS
Children's University Hosp.

Other Federal and State

Programs
Medicaid
Colorado Indigent Care Program (CICP)
Medicare
Tobacco class action lawsuit funds

Minority AIDS Initiative

PARTS A B C

Part B- ADAP outreach

Part A- Sub. abuse, mental health

2014 Funding

PART B (CDPHE):

PART A (DOHR):

Formula Part B $3,512,226.00

$7,990,359

ADAP $9,727,071.00

Increase of $533,831

MAI $68,366.00

ADAP Supplemental $0.00

($776,913.00)
TOTALS

$13,307,067.00

Decrease of $429,369.00 overall

Ryan White services are

critical to engagement in care

ADAP Advocacy Association

Jeffrey S. Crowley

Distinguished Scholar/

Program Director, National HIV/AIDS Initiative

Colorado AIDS Drug Assistance Program

Cost & Clients Served -2013

HMAP 2,039 enrollees 42,150 prescriptions $12,571,539.58*

BTGC 869 enrollees - 26,189 prescriptions $1,320,628.07*

HIAP 690 10,887 prescriptions $1,022,003.61*
$1,125,840 premiums, deductibles and co-pays

9/1/2012 8/31/2013 data provided by Colorado Department of Public Health & Environment

+25,000+ ACA-related Transitions

Facilitated by State HIV Programs
VT

WA
WA

ME

ND

MT

NY
MN

OR

WI

SD

ID

MI

WY

NV
CO

AZ

KS

OK
NM

IN

DE
WV
KY

MO

NC

TN
AR
MS

VA

GA

SC

AL

AK
TX

LA
FL

HI

Medicaid
13,000

QHPs
12,500

NJ

OH

IA
IL

CA

CT

PA
NE

UT

NH

MD
DC

Colorado ADAP / Insurance Status after

Implementation

13

2,100 individuals

300 individuals
1,181 insured patients
1,390 Medicaid /SWAP members

400 new HIAP members

110 new HIAP members

There is no similar assistance network for

any other disease state (cancer, diabetes, etc.)

What can you expect,

and what can be
expected of you?

HIV/AIDS has a unique status in complex

medical conditions

Cost of HIV medication alone through ADAP

for non-Medicaid members is anywhere from
$2500 to over $24,000 a year

HIV/AIDS is a public health issue as well

There is a higher incidence of substance

abuse and mental health issues in our
community

There are data sharing issues that need to be

addressed what can be shared, and for what
purpose?

-eligibility, adherence, crisis emergency

financial assistance?

Why its so important to recertify

every sixth months (last day/ mo.)
Implications of not recertifying

Cant get your medications,

(missed doses, would have to pay
your own costs)

HIAP cant pay your premium

until recertification is complete

Benefits to you

Colorado is working on a system

where recertifying with ADAP will
make you recertified for all Ryan
White services

If you lose your Medicaid or your

insurance temporarily, you can get
your medication through ADAP

You can get assistance in enrolling

in the proper assistance program

HIAP cant pay your co-pay

medical bills
Dont have to yell at ADAP staff

ADAP Eligibility Factors

CORE ADAP ELIGIBILITY FACTORS

All Colorado Plans

*

HIV +
CO Resident
400% FPL or below

SUB-PROGRAM ELIGIBILITY FACTORS

HMAP

BTGC

HIAP

SWAP

* Ineligible for any other

alternate payer source
No additional requirements.

* Medicare insurance
or full benefit
Medicare / Medicaid

* Private, group,
Marketplace, or COBRA
insurance
* Plan credibility determined

*Medicaid Eligible
(Under 138% of FPL
Includes those eligible
for Medicaid Buy-In

on case-by-case basis.

Ryan White Case Management Roles and Duties

CDPHE ADAP Office and Denver CAP for HIAP

Financial management

Eligibility and enrollment verification

CDPHE, DCAP,
ADAP OFFICE

Program management

Auditing/quality assurance

Social Workers, Medical & Non- Medical Case Managers

AIDS Service
Organizations &
Social Service
Entities

All program areas

Duties: Eligibility + enrollment assistance

Trouble shooting and client support

Health Insurance Assistance Program Coordination

HIAP
Coordination
Entities

Located at BCAP, DCAP, NCAP, SCAP & West CAP

Coordination of premium, co-insurance, and co-payments

No requirement to be case managed at the agency (can remain with other

ASOs)

Coordination of enrollment into Connect for Health Colorado with

assistance of Health Coverage Guides

HIV Medication Assistance

Program (HMAP)
No

annual limit

Medication

assistance only

Ramsell

Medication Assistance Card

$11,000

= average client cost per year.

Only

those individuals who cannot qualify for other insurance

or have temporarily lost coverage from Medicaid or insurance
will remain on HMAP

How is HMAP Assistance Provided?

HMAP Prescriptions filled by participating
pharmacies only:
Walgreens at Rose Hospital (mail-order)
Denver Health Infectious Disease Pharmacy
University of Colorado Infectious Disease Group
Practice
Walgreens at Childrens Hospital Aurora

Health Insurance Assistance

Program (HIAP)

Wraps around Employer, COBRA, and ACA marketplace insurance plans

Pays what the APTC and Cost sharing assistance available wont pay through
the marketplace

Premiums + medical and pharmaceutical deductibles, co-pays, and +

coinsurance up to $10,000 in aggregate

Patients must work with providers who are willing to bill for services
prescriptions paid through a Medication Assistance Card.

Assistance in enrollment through Connect for Health Colorado

Insurance Enrollment Sites

Boulder County AIDS Project

Colorado AIDS Project
Northern Colorado AIDS Project
Southern Colorado AIDS Project
Western Colorado AIDS Project

+
Supplemental Wrap Around Program (SWAP)

ADAP began a new program to cover all Medicaid-eligible

clients with medication co-pay coverage for ADAP
formulary

Members will be able to use many more pharmacies if they

choose (King Soopers, Walgreens)

Recertification process easier (as member would have been

screened eligible for Medicaid)

ADAP suggests that patients continue to use HMAP network

pharmacy at least at first - easy movement to HIAP, or to
HMAP if churning is an issue allows for back-billing.

The problem of CHURN

Problems presented by loss of
Medicaid

May not qualify for CICP or the

facility may not offer CICP

Enrollees often fail to notify

ADAP of change in situation
Enrollees need to notify
marketplace of change in income
affecting eligibility; tax penalties
and credits difficult to manage by
the program

May not be able to access same

providers under Medicaid, or may
have a waitlist

Enrollees can receive medication

assistance for ADAP formulary
drugs only through that time

Loss of Medicaid may mean up to

45 days until access to insurance is
established;

Problems presented by loss of job/

eligibility for marketplace insurance

Bridging the Gap, Colorado

State Pharmaceutical
Assistance Program
CMS-approved wrap-around program for HIV individuals with Medicare
Advantage & Medicare Part D, including premiums up to $80 a month. All
plans available if prescription drug benefit is included.
Coordinated training with the SHIP Navigators for choosing Plans
No skin in the game, enrollment through Medicare.gov is based completely
on patients prescription needs, desire to see specific provider, and choices re:
out of pocket costs.

Purpose and Objectives

Purpose
This presentation is to provide an overview on health insurance
and what the Affordable Care Act (ACA) is changing within the
structure of insurance plans

Objectives
Upon completion of this presentation you will:
Have a general understanding of health insurance
Understand common health insurance terms
Understand how to get help with payments through
ADAP

25

Cycle without Health Insurance

Uninsured consumer
can't afford doctor

Consumer drops policy

due to high price and is
now uninsured

Consumer delays care,

goes to ER

Insurers shift cost to

consumer

Consumer can't pay

Providers shift cost to

Insurers

26

+ Health Insurance Basics

The Value of Health Insurance

The 10 Essential Health Benefits

How to understand Health Insurance billing

27

Key Point

What are the Benefits of Health

Insurance?

Better Health

Peace of mind

Financial protection

Control in health care options

Ability to shop, compare and enroll online through Connect for

Health Colorado

28

29

TEN required essential health benefits

1. Ambulatory services

6. Prescription drugs

2. Emergency services

Ten Essential Health

Benefit
3. Hospitalization Categories

7. Rehabilitative and habilitative services and

devices

4. Maternity and newborn care

9. Preventive and wellness services and chronic

disease management

5. Mental health and substance use

disorder services, including behavioral
health treatment

10. Pediatric services, including oral and vision

care

8. Laboratory services

30

Preventative Care

Taking care of our health is often the best way to reduce our
health risks and our health costs. One of the most important
things we can do is get regular preventive care, like
immunizations and cancer screenings. Some health plans
already cover a range of preventive services at no cost to you
even if you havent met your deductible, or usually have co-pays
for other services. All health plans on the Exchange will cover
certain preventive services at no cost.

New health plans created after the ACA was signed on March 23,
2010, or plans that have changed their coverage since then, are
already required to cover preventive services for free. Older
plans that have stayed the same since the law was signed are
considered grandfathered. . If you arent sure if you have a
grandfathered health plan, review your plan documents, check
with your employer or contact your plan.

31

Free preventative services on

Medicaid, insurance, or Medicaid
This

applies only when these services are delivered by a

network provider.

Alcohol
Blood

Misuse screening and counseling

Pressure screening for all adults

Cholesterol

screening for adults of certain ages or at higher

risk
Colorectal

Cancer screening for adults over 50

Depression
Diabetes

pressure

screening for adults

(Type 2) screening for adults with high blood

32

Other free preventative services

Diet counseling for adults at higher risk for chronic disease

HIV screening for everyone ages 15 to 65, and other ages at increased risk

Immunization vaccines for adults--doses, recommended ages, and

recommended populations vary:

Obesity screening and counseling for all adults

Sexually Transmitted Infection (STI) prevention counseling for adults at

higher risk

Syphilis screening for all adults at higher risk

Tobacco Use screening

Marketplace Insurance: ADAP Wraps

around only certain plans

33

34

+
The ACA Individual Mandate

Key Point

What is the Individual mandate?

How does the mandate work?

What is Qualifying Health Coverage?
What if someone cannot afford insurance?
Are there Exemptions?

35

The Individual Mandate

Require all citizens and legal residents (there are some

exceptions) to have health coverage in 2014.

What happens if someone does not meet this deadline?

Will they go to jail?

NO!

36

What is the penalty?

Key Point

2014: $95 per adult

and $47.50 per child
(up to $285 for a
family) or 1% of
income, whichever is
greater

2015: $325 per adult

and $162.50 per child
(up to $975 for a
family) or 2%,
whichever is greater

2016: $695 per adult

and $347.50 per child
(up to $2,085 for a
family) or 2.5% of
family income,
whichever is greater

+ the Mandate IS SATISFIED WHEN

You were insured for the whole year through a combination of
any of the following sources:
Medicare
TRICARE
The veterans
A plan

health program

offered by an employer

Medicaid or

No Penalty. The
requirement to
have health
insurance is
satisfied

the Childrens Health Insurance Program (CHIP)

Insurance bought on your own or by ADAP that

the Bronze level

A grandfathered health plan

reform law was enacted

is at least at

in existence before the health

37

Types of Commercial Health Insurance

Health Maintenance HMOs

Preferred Provider Organizations PPOs

38

39

+ Health Maintenance Organizations (HMO)

Network providers and primary care physician

Co-payment

Lower out of pocket expenses

(Kaiser)

Key Point

In-Network

Individual must seek

care from

Health Care Professionals

Laboratory
Medical Facilities
Pharmacy
In-Network
Providers Only

+
Preferred Provider Organization
(PPO)

Contracted Preferred Provider List

More choice of providers

40

Higher costs for using non-Preferred Providers

Key Point

Yes! My providers
on this list!
Provider List

Choosing a provider from

the list = lower costs $$

Choosing a provider that is not on

the list = higher costs $$$$$

41

Estimated Premium

This is the amount of money that you

will pay monthly for your health
insurance coverage. This does not
include any out-of-pocket health
care expenses.

Cost Sharing

42

Key Point

Cost Considerations

Maximum Out-of-Pocket

Your choices determine your costs

43

Co-pays, Coinsurance &

Deductibles

The next columns correspond to details of your health plan. Co-pay

amount is what you are required to pay a provider for most visits.
Generally you pay this at the time of your visit. Check with your
provider to see if they will bill.

Under deductible amount, usually expressed as an annual total, you

see the amount you are required to pay for covered healthcare
services before your health plan will pay any benefits to you.

Co-insurance, usually a percentage of the cost that you would have to

pay.

+ Understanding Health Insurance Cost

Sharing

44

+ Things to Consider
about Health Insurance

Commercial private insurance

Coinsurance or copayment
Plan or calendar year deductible

Key Point

HMO limited
to InNetwork
Providers

PPO Your
choice of
contracted
Providers.

To find out if a provider is contracted

with a specific health care plan either
contact the providers office or the
health care plan and ask.

Contracting
Protection
Cost Sharing
Coinsurance = a percentage

45

Deductible

Copayment = a predetermined
amount

The Explanation of Benefits vs. the bill

or invoice for a service:

46

47

The Explanation of Benefits

Many people dont understand this form, and because it includes a notice
that it is not a bill, they discard it. But if you dont pay attention to your
EOBs, you may not get the maximum value of the health benefits you are
entitled to receive.
Information on Your EOB
Most EOBs start with identifying information specific to you and your plan.
If any of this information is incorrect, make sure to contact your plan
administrator.
The most important information on your EOB is a table that includes the
specifics of the services or procedures you have received. For each service
for which your provider is seeking reimbursement, there is a description of
the service along with a corresponding code and the date the service was
provided. If you have questions or require additional information, call the
phone number or visit the website shown on the EOB.
!

+ Charges Covered b y Your

Insurance
Following the service description is a column called billed or submitted
charges. This is the amount your provider billed you or your insurer for the
service. The next column may be called allowed charges, negotiated
amount or allowed amount (terminology may differ between insurers) this is the amount your plan agreed to pay network providers for the
service. However if your provider is not in your health plans network, this
amount reflects the price upon which your insurer will base any
reimbursement.
You will also see a column labeled not covered, not payable, or
pending - these are the charges your plan does not cover. Typically this is
the difference between what your provider billed and the allowed charge
covered by the plan. This is the portion you are responsible for paying.

48

49

Amount owed, or Patient

Responsibility:

The next columns add and subtract the charges and

deductions that appear previously on the EOB. Under
payable amount, or plan pays, you will see the total
amount your plan will cover.

This is equal to the allowed charge minus your deductible,

co-insurance (the percentage of covered charges that you are
responsible for), and co-pay amounts. The final column may
be labeled patient responsibility

Once again, since this is NOT A BILL, it should not be

submitted to Denver CAP HIAP for payment. Wait for the bill
to arrive.

50

Important:

Dont Make Payments Based on an EOB

Remember, dont make any payments based on the EOB -- it is not a
bill. If you havent already, you will receive a bill from your provider or
healthcare facility for the amount you owe.
If the EOB relates to a claim for which you already paid the provider, it
may contain a reimbursement check. If that is the case, you will see an
area on the EOB labeled payment enclosed or issued amount. Make
sure that you dont throw away your EOB without removing this check!
If you have questions about your EOB, or believe that your claim was not
resolved properly, contact your plan. The phone number is right there
on the EOB.
While the EOB may be complicated, understanding it can help
ensure that you and your family get the most out of your health
insurance!

Lets Review

Health insurance terms

Benefits of health insurance

Health insurance plan types

51

Knowledge Check
What is the definition of Estimated Premium?
A.

The percentage owed for each visit to a provider until the

deductible is met.

B.

The co-payment required until the maximum out of pocket

expenses are met.

C.

A deductible.

D.

The amount of money paid monthly for health insurance coverage.

This does not include any out-of-pocket health care expenses.

E.

All of the above.

52

Knowledge Check
What is health insurance?
A.Health insurance

is a contract between an individual and an

insurance company.
B.Health insurance

is something bought to protect against fire.

C.Health insurance

can be sold by a Navigator or In-person

D.Health insurance

is required for all dogs and cats.

Assister.

53

Knowledge Check
What is the Individual Mandate?
A.Every United

States citizen and legal resident (with no exceptions)

must have qualifying health care coverage or pay a penalty.
B.Every United

States citizen and legal resident (with some

exceptions) must have qualifying health care coverage or pay a
penalty.
C.Individuals are

mandated to have fire insurance.

54

Knowledge Check
This is the amount you and/or your family pay each policy period
before your health plan starts to pay for covered services.
A.

Co-Insurance

B.

Co-Payment

C.

Premium

D.

Deductible

55

Knowledge Check
Its the end of the year, 2014. I am an individual adult that decided
not to get qualifying health care coverage. What is the minimum
penalty I will be assessed.
A.The cost of one years

worth of premiums based on a bronze level

B.The cost of one years

worth of premiums based on a silver level

plan.

plan.

C.$95
D.The cost of one years

worth of premiums based on a gold level plan.

56

Knowledge Check
In a HMO an individual must seek care from
A.Any provider

they wish.

B.An In-Network provider.

C.A provider

theyve seen in the past.

D.The provider

that is closest to the individuals home.

57

Knowledge Check
Which of the following is not a characteristic of a PPO?
A.

They provide a Contracted Preferred Provider List

B.

Out of pocket costs are lower when an insured individual uses

providers from the Contracted Preferred Provider list.

C.

Insured must use In-Network providers, but ADAP wont pay for
service if it does not count toward the Out of Pocket Maximum.

58

Knowledge Check
An individual policy has a $200 yearly deductible and a 30%
coinsurance. This individual is not eligible for any cost sharing
reductions. The individual has not been feeling well and
decides to go to the Dr. for the first time. Will the individual
have any out of pocket costs and if so, what will they be?
A.This individual

is responsible for the first $200 of the bill.

B.This individual

is responsible for the first $200 of the bill plus

30% of anything over $200.
C.Nothing.

This is what they bought health care coverage for.

59

Knowledge Check
In the previous scenario the maximum out of pocket expense
the insured is responsible for is $2000. The insured has been
very ill and needs to go back to the Dr. for further treatment.
The insured has paid $1900 out of pocket to date. They have
already met their $200 deductible. This Dr. visit is $200. How
much will this visit cost the insured?
A.$100
B.$60
C.$40
D.$200

60

Knowledge Check
The insured has met their Maximum Out of Pocket expense. They go
to the Dr. and receive treatment that is not a covered service. What
amount of the bill will they be responsible for?
A.

$200

B.

30%

C.

All of it. The service was not covered

D.

None of it. This is why they purchased health care coverage

61

Knowledge Check
The insured has met their Maximum Out of Pocket expense. They go
to a Dr. and receive treatment for a covered service. The bill is
$173.50. How much of this bill is the insured responsible for?
A.

$17.35

B.

$52.05

C.

$173.50

D.

Nothing

62

Knowledge Check
Which of the following is not included in cost sharing reductions?
A.

Co-payments

B.

Co-insurance

C.

Premiums

D.

Deductibles

63

Questions

64

3
ADAP Advocacy Association

Jeffrey S. Crowley

Distinguished Scholar/

Program Director, National HIV/AIDS Initiative

The Future Role of

of the Ryan White
system

Enormous IMPACT of HEALTH

REFORM on PLWH/A in Massachusetts

IN MEDICAL
CARE

TAKING HIV
MEDICATIONS

Viral Load
Suppressed

US 41%
MA 99%

US 36%
MA 90%

US 28%
MA 72%

DIAGNOSIS & DEATHS

While

HIV Diagnoses increased by 2% nationally

between 2006 and 2009, there was a 25%
DECREASE in HIV Diagnoses in Massachusetts.

While

there was a significant decrease in US HIV

deaths during this period (33%), Massachusetts
beat this figure as well 44%)

+Leveraging the ACA to Raise the Bars:

Translating Coverage into Care and Treatment
SERVICE

QHP

MEDICAID/ RCCOs

RW/ ADAP

HIV Testing

Continue to cover in
certain settings

RX

Cost-sharing
assistance

CASE MANAGEMENT /
Care Coordination
ORAL HEALTH

RCCOs
LIMITED

LABS

Cost-sharing
assistance

MENTAL HEALTH
SERVICES

Cost-sharing
assistance

SUBSTANCE ABUSE
TREATMENT

Cost-sharing
assistance

HIV PRIMARY CARE

Cost-sharing
assistance

MEDICAL
TRANSPORTATION
INPATIENT HOSPITAL
SERVICES

Limited Coverage

Through HIAP

Ryan White Dental Providers

Howard
Denver

Dental

Health
Infectious Disease
clinic on Bannock

MCPN

Extending the benefits of HIAP to

other programs

MEDICARE RECIPIENTS

Created by Erin Dupuis, Boulder County AIDS Project, June 2012

MEDICAID RECIPIENTS

Targeted assistance to people in

crisis

Created by Erin Dupuis, Boulder County AIDS Project, June 2012

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COADAP

Questions?

Todd Grove
ADAP Coordinator Colorado
Department of Public Health &
Environment
303-692-2783
todd.grove@state.co.us

https://www.facebook.com/COADAP