What the Affordable Care Act (ACA) Means for HIV/AIDS Prevention Care and Treatment

Amy Killelea, JD NASTAD 2013 National Black AIDS Institute Webinar Series September 18, 2013

Presentation Overview

Three Questions

1. How Do I Apply for and Enroll in Coverage?

2. What Will My Coverage Look Like?

3. How Will the Ryan White Program Coordinate with New ACA Coverage Options?

Mapping Transitions

Uninsured •Lawfully present •Income up to 138% FPL

Medicaid

Uninsured •Lawfully present •Income 138 - 400% FPL

Subsidized private insurance through Marketplace

Currently on Medicaid No transition Currently on other government-sponsored insurance (e.g., Medicare, TRICARE)

No transition

Currently on or have access to employer-based coverage

If plan is affordable and comprehensive, no transition

Currently on PCIP or high risk pool Medicaid or Marketplace coverage

Uninsured and categorically ineligible for federal programs

No transition

Medicaid

Qualified Health Plan (QHP)

Federal Subsidies for Private Insurance: •Premium Tax Credits •Cost-sharing reductions

Navigating the Marketplace Web Portal

Federal Data Services Hub •SSN verification via SSA •Citizenship and immigration status via DHS •Incarceration verification via SSA •Title II benefits information via SSA •MAGI income from IRS

How Do I Apply for Coverage?

Streamlined Application and Enrollment – Income eligibility for Medicaid expansion and private

insurance subsidies determined using Modified Adjusted Gross Income No asset tests or income disregards Adjusted Gross Income minus certain income (e.g., alimony

and business expenses) Household = tax filing unit (individual and anyone the

individual can claim as tax dependent) – Open enrollment for Marketplace coverage: starts October

1st, 2013 and runs until March 31st, 2014

New Application Process: Simple and Streamlined

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

Plans Sold in the Marketplaces and Medicaid Expansion Must Cover Essential Health Benefits (EHB)

BUT, even with EHB requirements, there will be different plan options to choose from…

What Will My Coverage Look Like?

Is my provider on the plan’s network? – Marketplace plans MUST contract with “Essential Community

Providers” (ECPs), which include Ryan White providers Are my prescription drugs on the formulary? How much does my plan cost?

– Subsidies available for Marketplace coverage: Advance Premium Tax Credits available for people 100-

400% FPL Cost-sharing reductions for people 100-250% FPL

Check with your state’s ADAP to see if ADAP can help with premiums and cost sharing

What to Look for in Choosing a Plan

What to Look for in Choosing a Plan

Income (individual)

Second Lowest Cost Silver Level

Plan Premium

Individual Minimum

Contribution

Federal Premium Tax Credit

Annual Monthly Annual Monthly Annual Monthly Annual Monthly (Michael) 150% FPL

$17,235 $1,436.25 $4,500 $375 $689.40 $57.45 $3,810.60 $317.55

(Michelle) 300% FPL

$34,470 $2,872.50 $4,500 $375 $3,274.65 $272.89 $1,225.35 $102.11

Premium Tax Credits in Action

Know Your Rights and Protections

SERVICE QHP MEDICAID RW PART B / ADAP

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

How Will Ryan White/ADAP Coordinate with New ACA Coverage?

Example: Case Management Coverage

Private Insurance Benchmark Plan

Ryan White Program

Case management Periodic 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).

Resources

National Alliance of State & Territorial AIDS Directors (NASTAD), www.NASTAD.org – Amy Killelea, akillelea@nastad.org

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