Emily McCloskeyIntersection between the ACA and ADAP

April 10, 2014

A Year of Change: ADAP's Successes and Challenges Implementing the Affordable

Care Act

Who is NASTAD? NASTAD is a non-profit national association of state health

department HIV/AIDS program directors who administer HIV/AIDS and viral hepatitis prevention, care and treatment programs funded by state and federal governments. – Domestic Programs

Health Care Access, Health Equity, Prevention, Viral Hepatitis

– Policy and Legislative Affairs– Global Program

MissionNASTAD strengthens state and territory-based leadership, expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis.

VisionNASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.

Presentation Overview Current State of ADAPs ADAPs in a Reformed Health System Enrollment into Coverage Insurance Assistance and Premiums Leveraging the ACA to Raise the Bars Questions and Answers

Current State of ADAPs

The National ADAP Budget, by source, FY1996-FY2013

ADAP Client Utilization

ADAP Client Demographics

Non-Hispanic Black/African

American34%

Non-Hispanic White33%

Hispanic27%

Asian2%

Native Hawaiian/Pacific Is-lander<1%

American Indian/Alaskan Na-tive<1%

Multi-Racial1% Other

1%

Unknown2%

ADAP Clients Served, by Race/Ethnicity, June 2013

Male78%

Female21%

Transgender<1%

Unknown<1%

ADAP Clients Served, by Gender, June 2013

ADAP Client Demographics (continued)

<12 Years<1%

13-24 Years4%

25-44 Years41%45-64 Years

50%

>64 Years4%

Unknown<1%

ADAP Clients Served, by Age, June 2013

≤100% FPL43%

101-138% FPL10%

139-200% FPL15%

201-300% FPL13%

>400% FPL1%

ADAP Clients Served, by Income Level, June 2013

301-400% FPL 4%

Unknown 13%

ADAP Insurance Coordination

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 -

10,000

20,000

30,000

40,000

50,000

60,000

$-

$40

$80

$120

$160

$200

$240

$280

$320

$360

$400

5,272 7,167 7,277

12,311 13,744

20,960

15,843

30,621 34,341

41,095

46,653

52,568

$19 $30 $38 $75 $84

$75

$107 $159

$194

$268 $227

$397

Clients Served and Estimated Expenditures in Insurance Purchasing and Continuation, 2013

Num

ber

of C

lient

s (J

une)

Esti

mat

ed F

isca

l Yea

r Ex

pend

itur

es (

in m

illio

ns)

FY2014 Final FundingThe Bipartisan Budget Act of 2013 increased non-defense discretionary funding by $22 billion

Final numbers for FY2014 included a $14 million increase for ADAP

FY2015 Budget OutlookCaps for FY2015 are slightly larger than FY2014

President Obama’s budget released on March 4 ADAP and Part B were flat-funded

Congress is beginning work on the appropriations process

ADAPs in a Reformed Health System

ACA: Three Prongs

Public insurance reforms

Private insurance reforms

Health infrastructure

reforms

• Medicaid expansion

• Medicare Part D reforms

• Marketplaces/exchanges

• Prohibitions on discriminatory insurance practices

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

Challenges SolutionsHealthcare.gov has experienced significant glitches

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

Limited coordination between Marketplaces and Medicaid

Programs sent clients directly to Medicaid

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

ADAP in a Reformed Health System What will ADAP “look like” after January 1, 2014?

– Traditional ADAP Full payment of medications for those not eligible for

coverage under the Affordable Care Act– Insurance purchasing/continuation

Wrap-around of Medicaid and Medicare– Including Medicaid expansion and non-expansion

states Insurance purchasing – purchasing of a new policy

– Including policies purchased through the Exchange Insurance continuation – payment for an existing policy

– Including policies purchased through the Exchange

Enrollment into Coverage

Case Study: Ryan White Program Clients

≤100% FPL45%

101-138% FPL14%

139-200% FPL19%

201-300% FPL15%

301-400% FPL6%

>400% FPL2%

Unknown<1%

NASTAD Annual ADAP Monitoring Report, January 2013

2014 ACA Coverage Option Income Eligibility Threshold

Medicaid Expansion Income up to 138% FPL

Advance Premium Tax Credit for purchase of private insurance through exchanges/marketplaces

Income between 100 and 400% FPL (ineligible for Medicaid or affordable employer-based coverage)

Cost-sharing subsidies to offset out-of-pocket costs of private insurance through exchanges/marketplaces

Income between 100 and 250% FPL (ineligible for Medicaid or affordable employer-based coverage)

Unsubsidized private insurance coverage through exchanges/marketplaces

Income below 100% FPL (ineligible for Medicaid)

≤100% FPL45%

101-138% FPL14%

139-200% FPL19%

201-300% FPL15%

301-400% FPL6%

>400% FPL2%

Unknown<1%

≤100% FPL45%

101-138% FPL14%

139-200% FPL19%

201-300% FPL15%

301-400% FPL6%

>400% FPL2%

Unknown<1%

ADAP Clients Served, by Income Level (June 2012)

Mapping Client TransitionsUninsured• 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 (except for waiver beneficiaries)

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 coverageUninsured and categorically ineligible for federal programs

No transition

16,000+ ACA-related Transitions Facilitated by State HIV Programs

ID

MT

NV

WY

OR

AK

CO UT

CA

HI

NMAZ

WA

AL

ARGA

ID

IL IN

KY MO

MT

NV

NH

OH

SC

SD

TX

VA

WY

OK

ME

MD

NJ

NY

OR

AK

CO

LA

UT

CA KS

MS

FL

HI

NMAZ

NDMN

IA

WIMI

NE

WA

PA

NCTN

WV

VT

DE

CT

DC

Medicaid QHPs10,282 6,647

Enrollment into Coverage:Key Dates

15th

31st

Qualified Health PlansMARCH

• Enrollment Deadline for a Plan Effective Date of April 1st

• Enrollment Deadline for a Plan Effective Date of May 1st

• Deadline to switch plans

Medicaid CONTINUOUS ENROLLMENT

November 15, 2014 to February 15, 2015 Next open enrollment period pushed back

2015 QHP Open Enrollment Period

31stPCIPs April 30th

• PCIP coverage ends

Enrollment into Coverage:Where States stand on Medicaid

Source: Kaiser Family Foundation

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT

MO

MS

MN

MI*MA

MD

ME

LA

KY KS

IA* IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Implementing Expansion in 2014 (27 States including DC)Open Debate (5 States)Not Moving Forward at this Time (19 States)

Enrollment into Coverage:Medicaid Expansion Options

State decides to expand Medicaid to people with income up to 138% FPL (Yay!)

Traditional Medicaid

Alternative Benefits Plan that could be different from traditional Medicaid

Premium assistance program to purchase Qualified Health Plans (QHPs) for Medicaid beneficiaries

How to structure the expansion??

Weighing the Pros and Cons of Premium Assistance Plans

The GoodPolitically feasible way to get state

to expand MedicaidReduces churn between Medicaid

and QHPsMay allow access to bigger provider

networks

The ConcernsMay weaken Medicaid oversight and

protectionsStates are using 1115 waivers to ask for even

more flexibility from Medicaid rulesPrivate insurance is more expensive than traditional Medicaid, so may be difficult to

show that costs are “comparable”

Enrollment into Coverage:Mapping ACA Coverage Transitions

Uninsured• Lawfully present• Income up to 138% FPL

Medicaid

Uninsured• Lawfully present• Income 100 - 400% FPL

Subsidized private insurance through Marketplace

Uninsured and in non-Medicaid expansion state• Lawfully present• Income below 100% FPL

Unsubsidized private insurance through Marketplace

Currently on Medicaid No transitionCurrently 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 coverageUninsured & categorically ineligible for federal programs

No transition

Grantees are defining how to“vigorously pursue” client eligibility for Medicaid and QHP coverage

Churning

Enrollment into Coverage:Addressing Churn

Considerations to mitigate churn: Eligibility for premium tax credits and cost-sharing is based on

ANNUAL income If a person switches from a QHP to Medicaid and back to a QHP,

he/she will get credit for any cost-sharing charges paid before moving to Medicaid – BUT only if the the person re-enrolls in the same Marketplace plan from same insurer – This rule also applies any time someone re-enrolls in the same

Marketplace plan they had during the same year. State Medicaid policies (e.g., 12 month eligibility)

Medicaid(income up to 138% FPL)

Subsidies to Purchase QHP(income between 139 and 400% FPL)

Inco

me

fluct

uatio

ns

Enrollment into Coverage:The ACA and Immigrants

• >5 years in the country-Eligibleo Lawfully present immigrants are

banned from Medicaid eligibility for five years

• >5 years in country – Eligible for PTC (100-400% of FPL) and Cost sharing subsidy (100-250% of FPL)

• <5 years in country- Eligible for PTC (0-400% of FPL) and Cost-sharing subsidy (0-250% of FPL)

• Ineligibleo Eligible for Ryan White

• Ineligible for subsidies o Some State HIV Programs have

had success enrolling undocumented immigrants for unsubsidized QHPs outside of the Marketplace

Not

Law

fully

Pr

esen

tLa

wfu

lly

Pres

ent

Medicaid Qualified Health Plans

INDIVUAL MANDATE APPLIES (with exceptions as applicable)

INDIVUAL MANDATE DOES NOT APPLY

Special Consideration for Mixed Status Families

• Eligibility for coverage options and any applicable subsidies are available for the lawfully present members of the household

Enrollment into Coverage:Special Enrollment Periods

Trigger Event for Special Enrollment Period Coverage Effective Date

Loss of minimum essential coverage (NOT due to failure to pay premiums on time)

First day of month following plan selection

Gain of dependent through birth or adoption Day of birth, placement

Gain of an dependent through marriage First day of month following plan selection

Change in immigration status to citizen, national, or lawfully present

Regular coverage effective dates

Unintentional, inadvertent, or erroneous enrollments Regular coverage effective datesSubstantial violation of contract by insurance company Regular coverage effective dates

Enrollee is newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions

Regular coverage effective dates

Permanent moves that create access to new QHPs Regular coverage effective dates

Certain American Indians may enroll in QHPs one time per month

Regular coverage effective dates

Exceptional circumstances Regular coverage effective dates

Enrollment into Coverage:Individual Mandate Exemptions

Exemption How to ApplyBelow tax filing threshold (about $10,000 for an individual in 2013)

No need to apply; exemption is automatic

Hardship exemption (includes homelessness, natural disaster, and situation where person would have been eligible for Medicaid state had expanded)

Marketplace application OR federal tax return• Note: to be found eligible for the non-

Medicaid expansion state exemption, a person must receive a Medicaid denial.

Unaffordable coverage (defined as over 8% of household income)

Marketplace application• Note: a person eligible for an exemption

because coverage is unaffordable based on expected income may qualify to buy catastrophic coverage through the Marketplace.

Short coverage gaps (a gap that last less than three months)

Federal tax return

Indian Tribes Marketplace application OR federal tax returnInsular areas and territories No need to apply; exemption is automatic

Enrollment into Coverage:Enforcement of the Individual Mandate

IRS

Self-Attestation

Employers

Medicaid(including

SCHIP)

Medicare(including Advantage

plans)

Marketplaces

• Medicaid Outreach and Enrollment Activitieso Document vigorous pursuit of coverage options

• Maintain awareness of client insurance status and special eligibility opportunities o Manage client churno Advise special clients of special enrollment

periods Maintain awareness special and standard

coverage effective dates• Ensure O&E staff understand coverage options for

immigrants

Enrollment into Coverage:Considerations for State HIV Programs

Insurance Assistance and Premiums

Challenges Solutions

Issuers in several jurisdictions refuse to accept third-party premium payments from Ryan White/ADAP

Multi-pronged state and federal advocacy

Difficult coordination/communication with QHPs for timely submission of premium payments

Develop relationship with QHP contacts as well as Marketplace

Cost-effectiveness models have MANY variables

Utilize NASTAD model; peer models for assessing cost

Medical co-pays continue to be barrier to access to affordable care

Work across Ryan White Parts to identify and fill affordability gaps

Insurance Assistance and Premiums: :Top Four Challenges and Solutions

Insurance Assistance and Premiums:Ongoing Challenges

Insurance Company

Access to Care and

Treatment

ProviderData SharingHealth Department

1. Ev

aluati

on

2. Pr

emium

Paym

ent

Insurance Assistance and Premiums:Health Insurance Literacy

Insurance Assistance and Premiums:Augmenting Benefits Across Insurance ProgramsTypes of Insurance ADAP/Part B Assists Clients to Purchase

Types of Costs ADAP/Part B Covers

Employer-based coverage PremiumsCOBRA Prescription co-pays and co-insurance

PCIP Prescription deductiblesState high risk pools Medical co-pays and co-insuranceIndividual plans Medical deductiblesMedicare Part DMedicaid

Insurance Assistance and Premiums: 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

Insurance Assistance and Premiums:Assessing Provider Networks

HIV/Ryan White Providers

• Must include “Essential Community Providers,” but plans still vary on coverage

Pharmacy Network

• Are ADAP pharmacies (or pharmacies who will coordinate with ADAP) included?

• Do network pharmacies require mail order?

Insurance Assistance and Premiums: Tax Credits and Cost-Sharing Reductions

APPLICATIONPerson applies for premium tax credit and cost-sharing reductions during exchange open enrollment periods with either most recent tax returns or other documentation of income (e.g., pay stubs).

PAYMENTPremium tax credit is paid in advance on a monthly basis directly to the health plan. Payment amounts are based on income. ADAP may cover amount not covered by federal subsidy.

RECONCILIATIONWhen the person files a tax return for the actual year in which he/she received the tax credit, underpayments or overpayments are reconciled (overpayments are capped based on income).

Premium Tax Credits (available to people with income between 100 and 400% FPL)

Cost-Sharing Reductions(available to people with income between 100 and 250% FPL)

PAYMENTCost sharing reductions mean that plans pay a greater amount of the covered costs, taking that burden off of the enrollee. The cost-sharing subsidies are paid directly to the plan. ADAP may cover amount not covered by federal subsidy. 

2013 2014 2015

Insurance Assistance and Premiums: Tax Credits and Cost-Sharing Reductions

Consumer earns income and generates a modified adjusted gross income (MAGI) for the 2013 tax year

Consumer receives advance premium tax credit and cost sharing reductions based on 2013 MAGI

Consumer files 2014 tax return and reconciles 2013 MAGI with 2014 MAGI – under-/overpayment assessed by IRS

Leveraging the ACA to Raise the Bars

Leveraging the ACA to Raise the Bars:Translating Coverage into Care and Treatment

SERVICE QHP MEDICAID RW/ ADAP/CDCHIV Testing Continue to cover in

certain settingsRX Cost-sharing

assistanceMEDICAL CASE MANAGEMENTORAL 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

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 the ACA to Raise the Bars:Translating Coverage into Care and Treatment

Series10%

10%

20%

30%

40%

50%

60%

70%

80%

90%82%

66%

37%33%

25%

Diagnosed

Linke

d to

Car

e

Reta

ined

Vira

lly

Supp

ress

ed

Pres

crib

edAR

T

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 Programs and Providers

Breaking Down Program and Service Silos: Coordinated Care Opportunities through the

ACACoordinated Care Opportunities

Medicaid Health Homes- Targets populations with

chronic conditions, including HIV

Patient Centered Medical Homes- Certification emphasizes

whole-person care and role of vital enabling services in improving health outcomes

Contracting arrangements - Between support services

providers and medical providers

Quality and access measures - Include HIV quality

measures- Emphasize care

coordination

Capitated payments- Starting to include

support services

Resources

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

Questions and Answers

Contact Information

Emily McCloskeyManager, Policy and Legislative Affairs

NASTADPhone: (202) 434.8090 

emccloskey@NASTAD.orgwww.NASTAD.org