Amy Killelea, NASTAD North Dakota 2014 HIV/STD/TB/Viral Hepatitis Symposium September 18, 2014

Amy Killelea, NASTADNorth Dakota 2014 HIV/STD/TB/Viral Hepatitis Symposium

September 18, 2014

ACA and Public Health: Successes, Challenges, and Priorities

Moving Forward

Presentation Overview

Part 1: ACA Opportunities: Where We Are and Where We’re Going

Part 2: Implementation in Action:• Preparing for outreach and enrollment into new

ACA coverage options• Assessing and filling coverage gaps• Assessing and filling affordability gaps• Preparing providers for a changing health care

landscape

Questions/Discussion

About NASTAD

NASTAD is an international non-profit 501(c)(3) association of U.S. state health department AIDS directors who administer HIV/AIDS and viral hepatitis programs funded by U.S. state and federal governments

NASTAD was established in 1992 as the voice of the states

NASTAD is governed by a 20 member, elected Executive Committee (EC) charged with making policy and program decisions on behalf of the full membership

NASTAD has a Washington, DC headquarters and field offices/programs in Bahamas, Botswana, Ethiopia, Haiti, Mozambique, South Africa, Trinidad, Uganda and Zambia

Part 1ACA Opportunities: Where We Are and

Where We’re Going

ACA: Three Prongs

Public insurance reforms

Private insurance reforms

Health infrastructure

reforms

• Medicaid expansion

• Medicare Part D reforms

• Marketplaces• Prohibitions on

discriminatory insurance practices

• Investments in community health centers, health workforce, coordinated care, and prevention

ACA Insurance Expansions

ChildrenPregnant women

Working parents

Jobless parents

DisabledChildless adults

0%

50%

100%

150%

200%

250%

300%

350%

400%

Federal Poverty Level (FPL)

Current Medicaid/CHIP Eligibility

ChildrenPregnant women

Working parents

Jobless parents

DisabledChildless adults

0%

50%

100%

150%

200%

250%

300%

350%

400%

Medicaid Expansion 138% FPL

ChildrenPregnant women

Working parents

Jobless parents

DisabledChildless adults

0%

50%

100%

150%

200%

250%

300%

350%

400%

Medicaid Expansion 138% FPL

Subsidies for private insurance400% FPL

66% of Ryan White Clients had income below 100% FPL (in 2011)

Where States Stand on Medicaid Expansion

Source: Kaiser Family Foundation, August 28, 2014

Part 2: Implementation In Action

ACA and Public Health ProgramsYear One: Redux

Pu

blic

Healt

h P

rogra

ms Client transition and enrollment

Coverage gaps

Affordability gaps

Coordination & integration of public health providers and services with

broader health systems

Over 25,000 ADAP Clients Transitioned to Medicaid Expansion and Qualified Health Plans

(as of May 2014)

AL

ARGA

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IL IN

KY MO

MT

NV

NH

OH

SC

SD

TX

VA

WY

OK

ME

MD

NJ

NY

OR

AK

CO

LA

UT

CAKS

MS

FL

HI

NMAZ

ND

MN

IA

WIMI

NE

WA

PA

NCTN

WV

VT

DE

CT

DC

Medicaid QHPs Total12,004 13,129 25,133

ACA Outreach and Enrollment Programs and Resources

Consumer outreach

and enrollment

Patient Navigator Program

Insurance Assisters

Certified Application Counselors Community

Health Centers

Enroll America

HIV/AIDS Care Programs and Providers

HIV

Pre

venti

on P

rogr

ams

?

Coordinating Enrollment to Ensure No Disruptions in Care

Open Enrollment for Marketplace Coverage

Open enrollment (October 1st through March 31st in first year) and limited special enrollmentBased on MAGIDates matter! Coverage effective date depends on when you apply and payment of premium

ADAP Application and Recertification

Continuous enrollment6 month recertificationBased on MAGI?

Medicaid

Continuous enrollment Based on MAGI (for new expansion group)

Challenges Solutions

Healthcare.gov has experienced significant glitches

Programs worked directly with plans to enroll clients; urging case managers to build in extra time to assist clients

“Vigorously pursue” is difficult to define

Programs developed policies and procedures to screen clients for coverage, maximize enrollment, but continue to provide safety net for remaining uninsured

In certain states, participation in ACA enrollment by state employees is limited or prohibited

Programs worked with community organizations and coalitions to coordinate client education, outreach, and enrollment efforts

Qualified Health Plan (QHP) information has been incomplete or unavailable

Programs have had some success reaching out directly to plans for information

Recap of 2014 Open Enrollment: Top Four Challenges and Solutions

New Coverage Opportunities

Plans must cover 10 Essential Health Benefits (EHB) Scope of coverage will vary – but clients and providers

should look for THREE things:– Does the provider network include HIV providers?– Does the formulary include client’s treatment

regimen?– How much does the plan cost?

Preventive and wellness

services

Laboratory services

Ambulatory services

Prescription drugs

Maternity and newborn care

Emergency services

Rehabilitative and habilitative

services

Mental health and substance use

disorder services

Pediatric services

Hospitalization

New Coverage Opportunities for Prevention

ACA PREVENTIVE SERVICES REQUIREMENTS (PARTIAL LIST)

Private Insurance Medicaid Expansion Medicare USPSTF A and B rated services including: Routine HIV screening Hepatitis C screening for at-risk

individuals Chlamydia/syphilis/gonorrhea

testing for at-risk individuals STI counseling Tobacco counseling and

screening

Women’s preventive services, including: Routine HIV screening HPV screening Well woman visits Contraception and counseling Domestic violence screening

and counseling  No cost-sharing for these

services

 USPSTF A and B rated services including: Routine HIV screening Hepatitis C screening for at-risk

individuals Chlamydia/syphilis/gonorrhea

testing for at-risk individuals STI counseling Tobacco counseling and screening

Women’s preventive services, including: Routine HIV screening a HPV screening Well woman visits Contraception and counseling Domestic violence screening and

counseling

States may provide these services to traditional Medicaid beneficiaries and will get increased federal funding if they do so

 Annual wellness visit HIV screening for those at increased risk and for those who request a test*  No cost-sharing for these

services

* CMS is in process of issuing new coverage determinations adopting USPSTF revised recommendations for Medicare.

Coordination Across Payers:Translating Coverage into Care and Treatment

SERVICE QHP MEDICAID RW/ ADAP/CDC

HIV Testing Continue to cover in certain settings

RX Cost-sharing assistance

MEDICAL CASE MANAGEMENT

ORAL HEALTH

LABS Cost-sharing assistance

MENTAL HEALTH SERVICES

Cost-sharing assistance

SUBSTANCE ABUSE TREATMENT

Cost-sharing assistance

HIV PRIMARY CARE Cost-sharing assistance

MEDICAL TRANSPORTATION Limited Coverage

INPATIENT HOSPITAL SERVICES

Adapted from West Virginia Ryan White Part B Program

Example: Case Management Coverage

Private Insurance Benchmark Plan

Ryan White Program Medicaid

Case managementPeriodic phone calls to discuss appointments and assist in finding services. 

Medical case management Coordination and follow-up of medical treatments, ongoing assessment of the client’s and other key family members’ needs and personal support systems, development of a service plan, coordination of services, provision of treatment adherence counseling to ensure readiness for, and adherence to HIV/AIDS treatments.

Non-medical case management Includes provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services (does not include coordination and follow-up of medical treatments).

Targeted case managementOptional benefit that allows states to provide a range of care coordination and support services to eligible beneficiaries. Eligibility criteria typically require high level of need.

Medicaid Health Home ProgramNew option that allows states to provide a range of care coordination services (including care management, patient and family support, referral to community and social support services, and use of health information technology to link services) to high-need Medicaid beneficiaries with chronic conditions (including HIV).

Significant Coverage Gap: Prescription Drug Formulary

EHB Standard = same number of drugs per U.S. Pharmacopeia (USP) category/class as state’s benchmark plan

USP Category

USPClass

Anti-viral NRTIs

NNRTIs

Protease inhibitors

Anti-Cytomegalovirus (CMV) agents

Anti-hepatitis agents

Other

Missing from USP classification system = combination therapies

Assessing Qualified Health Plan (QHP) Metal Tiers

QHP Metal Tiers

What It Means

Bronze Plan pays 60% of costs (on average)/enrollee pays 40%

Silver Plan pays 70% of costs (on average)/enrollee pays 30%

Gold Plan pays 80% of costs (on average)/enrollee pays 20%

Platinum Plan pays 90% of costs (on average)/enrollee pays 10%

Lower premiums, but less generous

Higher premiums, but more generous

Clients must enroll in a silver level plan to get cost-sharing reductions

Premium tax credits to help offset cost of Qualified Health Plan premiums available for people with income up to 400% FPL

Cost-sharing reductions to reduce out-of-pocket costs available for people with income up to 250% FPL

Assessing and Filling Gaps in Affordability

Affordability Gaps Will Remain…

OOP Costs for QHP Coverage

Medical visit $25

ARVs 30% co-insurance

Outpatient mental health visit

$25

OOP annual cap = ~$2,100-$6,300

Income (monthly)

Second Lowest Cost Silver Premium (monthly)

Individual Minimum Contribution (monthly)

Federal Premium Tax Credit (monthly)

Mike(150% FPL)

$1,436.25 $375 $57.45 $317.55

Mary(300% FPL)

$2,872.50 $375 $272.89 $102.11

Other insurance purchasing considerations:– Does plan meet HRSA/HAB insurance purchasing

requirements (cost-effectiveness and formulary adequacy)

– Are providers and pharmacies in the plan network?– Which plans have co-pays instead of co-insurance?

ADAP purchasing QHPs (premiums, Rx co-pays, or deductibles)

ADAP piloting QHP purchase

ADAP not currently purchasing QHPs (most are planning)

AL

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KY MO

MT

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OH

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TX

VA

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OK

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MD

NJ

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OR

AK

CO

LA

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CAKS

MS

FL

HI

NMAZ

ND

MN

IA

WIMI

NE

WA

PA

NCTN

WV

VT

MA

RI

DE

CT

DC

ADAP/Part B Programs Currently Purchasing Qualified Health Plans (QHPs) for Clients (June 2014)

Even after full ACA implementation, there will be populations left out of reform:– Low-income individuals in states that do not

expand Medicaid– Undocumented populations– Hard-to-reach “eligible but not enrolled”

populations

Assessing the Gaps: Planning for Public Health Safety Net

HRSA/HAB ACA Policies

HRSA encourages state ADAP/Part B Programs to use their Ryan White funding to help clients access insurance, as long as:– Formulary includes at least one drug in each class of core ARVs

from the HHS Clinical Guidelines– It is cost-effective in aggregate as compared to purchasing

medications Other Ryan White Program grantees may also use their funds to

help clients with the cost of insurance The Ryan White Program is the payer of last resort and grantees

must “vigorously pursue” client eligibility for public and private insurance– Grantees may not dis-enroll clients from services for failure to

enroll in public or private insurance coverage Ryan White Program funds may be used to cover services not

covered or inadequately covered by public and private insurance

Preparing Providers for Health Reform

Local preparation for health reform

Relationship w/safety net

providers

Preparation for insured clients (e.g., billing)

Preparation to provide vital enabling services

not covered by ACA insurance expansion

Strategic planning to

negotiate new health care landscape

Leveraging New Resources/Payers: It’s Complicated!

Service covered?

Provider in network and credentialed with payer?

Does reimbursement

cover cost of service?

What is impact on

client/patient?

Translate public health service into language of payers/insurance (e.g., CPT codes)

Assess provider requirements (licensed provider; provider supervision; provider recommendation; setting)

Compare reimbursement rate (within capitation or FFS) with cost of providing service

Are privacy and confidentiality concerns addressed?

A Changing Public Health Role

NHAS Goals• Reduce new infections• Increase access to care• Reduce health

disparities

ACCOUNTABILITY

PayersPrivate• Qualified Health Plans• Other private insurersPublic• Medicaid• Medicare

Medical Providers• Private physicians• Community health

centers• Hospitals • Specialty clinics

Community-Based Providers

• Community-based organizations

• Outreach workers• Peers

State Health Departments

• Prevention programs• Surveillance

programs• Safety net care and

treatment programs

Questions

Resources

National Alliance of State & Territorial AIDS Directors (NASTAD), www.NASTAD.org – Amy Killelea, [email protected]

HIV Health Reform, http://www.hivhealthreform.org/ Treatment Access Expansion Project, www.taepusa.org HIV Medicine Association, www.hivma.org Health Care Reform Resources

– State Refo(ru)m, www.statereforum.org– Kaiser Family Foundation, www.kff.org – Healthcare.gov, www.healthcare.gov