WHAT DOES IT MEAN FOR PEOPLE WITH HIV?

PAETCJuly, 2012

ANNE DONNELLYPROJECT INFORM

ADONNELLY@PROJECTINFORM.ORG415.558.8669X208

Health Care Reform

Presentation Outline

Part One: The Supreme Court Decision

Part Two: The Next Decision Point:

Elections

Part Three: Changing HIV/AIDS Care

Landscape

Part Four: Implementation Priorities

Part Five: Considerations for AETCs

WHAT WILL HAPPEN WITH HEALTH CARE REFORM?

The Supreme Court and Elections

Supreme Court Decision – Largely a Win

Opponents challenged constitutionality of the individual mandate and the Medicaid expansion and SCOTUS issued a decision

The law is largely

upheld

The individual mandate is upheld as a tax

penalty

Medicaid expansion remains – no federal

penalty for states which don’t enact

Serious Concern - Medicaid Expansion

Expansion is still in effectFederal government pays 100% for 2014 – 2016

Gradually reduces to 90% by 2020

The federal government can’t take away traditional Medicaid funding if states refuse to participate

26 states joined in the lawsuit claiming “coercion” by the federal government to take the expansion funding Very bad if for low-income people if states don’t enact

expansion Lots of financial and political pressure to enact post election

2012 Elections = Next Watershed for Health Care

2012 Elections = Next Watershed for Health Care

Health Care Reform – A Changing Care Landscape

Creates a provision that citizens must carry health insurance Tax penalties apply to those who do not Exemptions for hardship and some other reasons

Coverage expansions are – in effect – a mandate for people with HIV who want to stay in care Ryan White payer of last resort rules

New Responsibilities

Medicaid: Improved and Expanded

Currently Medicaid is – for most with HIV – disability coverage

In 2014: Expanded Eligibility

The disability requirement is eliminated Most people with income up to 138%FPL will be

eligible for Medicaid/Medi-Cal (appr. $15K for an individual)

No asset test Could Improve Services

Medicaid expansion includes Essential Health Benefits (EHB) for newly eligible people

Improves Access to Private Insurance

Improves Access to Private Insurance

Insurance ReformsState-Based Exchanges

Consumer friendly marketplace to purchase private insurance

Federal subsidies for people with income up to 400% FPL

Plans must provide essential health benefits

Can’t be denied or dropped from insurance because of HIV (all plans)

Can’t be charged higher premiums because of HIV or gender (exchange plans)

No more lifetime and annual limits (all plans)

Prevention services (including routine HIV testing for women) must be covered without cost sharing (all plans)

Caps amount spent out of pocket (exchange plans)

Increases Access to Medicare Part D

50% discount on all brand-name prescription drugs

AIDS Drug Assistance Program (ADAP) contributions now count toward copayment obligations, allowing people with HIV to move through the “donut hole”

Part D “donut hole” phased-out by 2020

Other ACA Improvements

Essential Health Benefit provision establishes new floor for benefits

Mental health (MH) and substance use disorder (SUD) tx part of EHB Mandatory coverage for MH and SUD at parity New opportunities in primary care and integrated services

Invests in Prevention, Wellness, Access to Care and Innovation Prevention and Public Health Fund Community Health Center Expansion Health Work Force Investments Care Coordination Investments

Health Care Reform and Immigrants

Certain immigrant populations are completely excluded from health care reform

Undocumented individuals are not eligible for: Medicaid Health Insurance Exchange Subsidy

Legal immigrants continue to face a five year waiting period for Medicaid Exceptions to five year waiting period include

people seeking asylum, refugees and some others

Care Landscape in 2014

Individuals with income up to 138% FPL

Eligible for Medicaid based on income alone (Ryan White Program still needed to fill in gaps not covered by Medicaid)

Individuals between 138% and 400% FPL

Eligible for premium tax credits and cost-sharing subsidies to purchase private insurance (Ryan White Program still needed to fill gaps in coverage and affordabilitye)

Individuals with unmet care and treatment needs

Ryan White Program still a safety net for: insured people with unmet need and gaps in services legal immigrants not eligible for Medicaid, and undocumented immigrants

PRIORITIES FOR PEOPLE WITH HIV

It’s All About State Implementation

1. Ensuring Medicaid Expansion in All States

States could refuse Some have said they will

Some states began to challenge current Maintenance of Effort requirements Sec. Sebilius sent letter advising current requirements

are in place and wants to work with States on expansion opportunities

Strong incentives in terms of fundingStrong allies to “convince” reluctant Governors

Hospital associations, pharmaceutical companies, health advocates

2. Ensuring a Comprehensive Essential Health Benefits PackageACA Essential Health

Benefits• Ambulatory services • Emergency services • Hospitalization • Maternity/newborn care • Mental health and substance

use disorder services – to parity

• Prescription drugs • Rehabilitative and habilitative

services• Laboratory services • Preventive and wellness

services and chronic disease management

• Pediatric services

Federal Guidance/Regulations

State Implementation

Decisions

• Flexibility for most states likely means bare bones plans• State variation and disparities will continue

• Continued federal advocacy needed to enforce anti-discrimination protections

• California:• Decisions are being made now• Legislature and Exchange Board are working together• Benchmark plan: Kaiser small group plan for Exchange• Medicaid benchmark guidance not complete

• Choices of FEHBP, State Employees, Largest commercial HMO, Secretary determined equivalent

• Advocates say Medi-Cal plus - administrative burden much lower

What Does a Benchmark Approach Mean?

What Does a Benchmark Approach Mean?

3. Ensuring Access to Ryan White: Filling the Gaps

Essential services needed by people living with HIV/AIDS NOT fully covered by EHB: Dental services Case management Medical case management? Nutrition services Transportation Mental health and substance use services Peer support services Insurance assistance

Medicaid will NOT be available for: Undocumented immigrants Legal immigrants within the 5 year ban

Ryan White HIV/AIDS Program

MA: Post HCR ADAP Costs

4. And 5. Transitioning to New Systems

Ryan White programs and support systems created a relatively seamless system of care

Both people with HIV and HIV providers will need to transition to new forms of coverage

There is no one agency/individual “in charge” of this massive transition It involves multiple agencies (previously siloed) working

together in new ways

4. And 5. Transitioning to New Systems

-No effective communications system for providers and/or clients

-Little to no information materials -Details of new systems in development

/changing -Little clear guidance from agencies -No clear assistance for clients -No comprehensive technical assistance for

providers (medical and non-medical) -Inadequate provider rates, including pharmacy

-Become a Federally Qualified Health Center (FQHC)

Affiliate or integrate w/a FQHC Successful integration in Sonoma County

-Diversify FundingNeed as many different types of coverage/insurance as possible

-Prepare for an insured client base

-Look at data systems

-Strategize about when and where Ryan White must fill gaps

5. Preparing for Change in HIV Care

6. Making Medicaid Managed Care Work

-Ensure HIV providers are part of the managed care network and can be identified

-Consider state – specific enhanced reimbursement strategies

-Consider pharmacy networks as well as medical providers

-Transition from fee-for-service to managed care critical Clear and effect continuity of care protections are

essential

-Medicaid Health Home Program Opportunities

WAYS THAT AETCS COULD SUPPORT PROVIDERS DURING HEALTH CARE

REFORM

Consideration for AETCs

Health Care Reform and Disparities:Long term – positive; short term - challenges

AETCs Supporting Providers Through HCR

• Information• No communication or education plan• HIV providers will need to understand changes; how

it affects them and their clients; more about broader systems of care

• Planning• Clinics will have to realistically plan how they and

their clients will transition to new systems• Best done in dialogue internally and with other

clinic systems

• Identifying and providing technical assistance where needed• Can providers contract with, bill, and interact with Medicaid,

private and public managed care organizations, private insurance?

• How could warm lines support providers with information/TA?

• Supporting engagement in advocacy• Providers are needed in policy development

• Adequate formularies with new coverage Supporting Testing, Linkage, Engagement and

Retention in Care Identification and dissemination of best practices Identification and dissemination of best transition practices

Work with providers to create “best practices”

AETCs Supporting Providers Through HCR

AETC Support

• AETCs - change facilitators?• Planning for the unknown is hard

– Details, details, details: state and local level• Collaboration and partnership are essential

– Adaptive versus technical change; Cross sector participation important

– If partnerships are developed in advance, trust makes planning easier

– Easy to waste time and get frustrated by blaming others

• Fear of change is part of the process– Openly addressing fears and seeking opportunities

are important steps in the process

Health Care Reform Planning

“The causes of today’s problems are complex and

interconnected. There are no simple answers, and

no one individual can possibly know what to do - it

is time to stop waiting for someone to save us.

We’re all in this together, we all have a voice in how

we go forward.”

Meg Wheatley

Resources

www.hivhealthreform.org Community based website with California sub-site

FamiliesUSAhttp://www.familiesusa.org/health-reform-central/

Summaries, fact sheets, issue briefs; Join listserv for information updates, including periodic national conference calls on health reform topics

Kaiser Family Foundationhttp://healthreform.kff.org/

Summaries and implementation timeline; Fact sheets on Part D, exchanges and subsidies

Treatment Access Expansion Projecthttp://www.taepusa.org/

Analysis of HIV-related provisions, including presentations

HealthReform.govhttp://www.healthreform.gov/

Administration website with information on the new law, including an ongoing Q&A forum and state-specific information

Center for Medicare Advocacyhttp://www.medicareadvocacy.org/

Policy analysis and beneficiary information on the new law’s impact on Medicare, including Part D