HIV/AIDS CARE IN A CHANGING HEALTHCARE LANDSCAPE

Medicaid Expansion

What’s New for 2015

DISCLOSURES

•  This presentation covers general information on the impact of healthcare reform and its overall effects on HIV/AIDS care •  This presentation is presented for information purposes only and is

not meant to be preferential in any one direction •  The information presented here is current as of December 2014.

However, federal regulations, state actions, and policy developments related to healthcare reform are dynamic and may change frequently •  Thus, some information in this presentation may become outdated •  The information provided represents no statement, promise,

or guarantee by Janssen Therapeutics, Division of Janssen Products, LP, concerning coverage, levels of reimbursement, payment, or charge. Please consult your payer organization with regard to local or actual coverage and reimbursement policies and determination processes

2

OBJECTIVES

•  Review aspects of healthcare reform and Medicaid expansion central to the care of people with HIV/AIDS •  Discuss the implications of these initiatives for physicians who

provide care for people with HIV/AIDS •  Provide opportunities for discussion of the effects of healthcare

reform on access to care for people with HIV/AIDS

3

MEDICAID EXPANSION

10 MILLION NEW PEOPLE JOIN MEDICAID THROUGH ACA EXPANSION

•  The Affordable Care Act (ACA) changed Medicaid from a category-based entitlement to one based on income (≤138% of the federal poverty level [FPL]), opening the doors for 10 million people who previously were uninsured1

•  12,000 uninsured people who received assistance from the AIDS Drug Assistance Program (ADAP) in 2013 are now covered by Medicaid3

5

1.  Centers for Medicare & Medicaid Services. Medicaid & CHIP: September 2014 monthly applications, eligibility determinations and enrollment report. November 19, 2014.

2.  Obamacare Facts. Federal poverty level 2014–2015. 3.  National Alliance of State and Territorial AIDS Directors. ADAP supports expanded

access to care. June 2014.

Household size Income threshold

1 $16,105

2 $21,707

3 $27,310

4 $32,913

5 $38,516

6 $44,119

Medicaid eligibility, 2014–2015*2 56,000 ADAP

clients uninsured

45% gained new coverage†

12,000 placed in Medicaid

*In states expanding Medicaid.

†New coverage of any type, including Health Insurance Marketplaces and Medicaid.

MORE THAN HALF OF STATES HAVE EXPANDED MEDICAID

•  As of December 17, 2014, 28 states (including DC) have expanded their Medicaid programs1

–  Total is up from 24 states on July 1, 20132

6

1.  Kaiser Family Foundation. Status of state action on the Medicaid expansion decision, as of December 17, 2014. 2.  Kaiser Family Foundation. Status of state action on the Medicaid expansion decision, as of July 1, 2013. 3.  Kates J, et al. Assessing the impact of the Affordable Care Act on health insurance coverage of people with HIV. Kaiser Family

Foundation. January 2014.

If all states expand Medicaid, another 35,000 Ryan White clients could qualify

for Medicaid.3

Not Moving Forwardat This Time

Moving Forwardat This Time

Under Discussion

NJ

MA

CT

RI

DE

MD

DC

ME

NY

PA

WVVA

NCTN

KY

OHINIL

IA

MIWI

MNNDMT

ID

WA

OR

CA

NVUT

WYSD

NE

KS MO

AR

LATX

NMAZHI

AK

CO

OK SC

GAALMS

FL

NH

VT

SOUTHERN NONEXPANSION MIRRORS RATES OF HIV/AIDS PREVALENCE

•  Rate of adults/adolescents living with an HIV/AIDS diagnosis (per 100,000 people, by county, 2010)1

7

1.  Aidsvu.org. Accessed October 24, 2014. 2.  National Alliance of State and Territorial AIDS Directors. National ADAP monitoring project annual report. February 2014.

31,000 ADAP clients fall into the coverage gap in nonexpansion states in the South.2

0 to 4041 to 5455 to 6768 to 8283 to 103104 to 134135 to 174175 to 244245 to 383384+Data Unavailable

DEMOGRAPHICS OF MEDICAID NONEXPANSION

•  In states that didn’t expand Medicaid, ADAPs are paying for unsubsidized Marketplace coverage (for people <100% FPL) to keep people with HIV/AIDS linked to care2

•  Childless adults—who make up a sizeable portion of the HIV/AIDS population—remain ineligible for Medicaid

1.  Kaiser Family Foundation. Understanding the effect of Medicaid expansion decisions in the South. JAMA. 2014;311:2471. 2.  National Alliance of State and Territorial AIDS Directors. ADAP supports expanded access to care. June 2014.

of FPL: Median income cutoff for Medicaid

eligibility for parents in the South1

8

of the 4.8 million uninsured adults in the

coverage gap are in the South1

NEW MODELS PROMPT SOME STATES TO MOVE FORWARD

•  States that originally rejected Medicaid expansion reopened the debate when the Centers for Medicare and Medicaid Services (CMS) began granting waivers for private alternatives

–  Private alternatives reduce churn between Medicaid and Marketplace plans and may allow access to larger provider networks1

9

1.  McCloskey E. A year of change: ADAPs successes and challenges implementing the Affordable Care Act. Presented at NASTAD, April 10, 2014. 2.  Mukherjee S. Why Arkansas’ newly approved alternative to Medicaid expansion is a big deal for Obamacare. ThinkProgress.org.

September 27, 2013. 3.  Mukherjee S. Iowa’s alternative to Obamacare’s Medicaid expansion wins federal approval. ThinkProgress.org. December 10, 2013.

4.  Mukherjee S. After initially refusing Obamacare’s Medicaid expansion, Pennsylvania’s GOP governor reverses course. ThinkProgress.org. September 16, 2013.

5.  Collins SPK. Virginia governor expands health care to 25,000 people in the Medicaid coverage gap. ThinkProgress.org. September 8, 2014. 6.  Vozella L. With Medicaid expansion blocked, McAuliffe unveils modest plan to insure more Virginians. The Washington Post. September 8, 2014.

7.  National Alliance of State and Territorial AIDS Directors. National ADAP monitoring project annual report. February 2014.

Enacted with CMS approval

Arkansas •  Medicaid funds subsidize all premium costs for silver Marketplace plans for people <138% FPL2

Iowa •  Medicaid funds subsidize a portion of Marketplace premium costs for people 100%–138% FPL; beneficiaries pay for rest of premium •  Premiums for people <100% are fully subsidized3

Pennsylvania •  Imposes some premium costs for people 50%–138% FPL •  Includes work-search requirements for some beneficiaries4

Enacted by gubernatorial order

Virginia •  Uses other state funds to enroll people who are in the coverage gap (<100% FPL) into Medicaid,5,6 potentially covering almost 2,000 ADAP clients7

PRIVATE ALTERNATIVE PROVISIONS RAISE CONCERNS

•  Enrollment premiums may be a hardship for some low-income people –  Federal Medicaid regulations prohibit premiums for people <150% FPL1

–  Pennsylvania waiver and Indiana proposal would lock beneficiaries out of Medicaid for nonpayment of premiums1,2

•  Limitations placed on traditional Medicaid benefits to offset costs may result in inadequate care for people with HIV/AIDS –  Pennsylvania limits frequency of lab tests and number of medications to

6 per month1

–  Iowa waiver and Indiana proposal do not allow nonemergency transportation to medical appointments1,2

•  Patient advocates concerned about complexities and impracticalities –  Indiana proposal stratifies new beneficiaries into different benefit- and

cost-sharing arrangements2

–  Pennsylvania waiver’s work-search requirement may be impractical for people with HIV/AIDS who are too sick to work1

10

1.  HIV Healthcare Access Working Group. Proposed healthy Pennsylvania 1115 demonstration project and other 1115 waiver proposals. Letter to CMS. April 10, 2014

2.  HIV Healthcare Access Working Group. Proposed healthy Indiana plan 1115 demonstration project. Letter to HHS. September 21, 2014.

PEOPLE ON EDGE OF MEDICAID ELIGIBILITY CHURN THROUGH BENEFIT PLANS

Income fluctuations cause people to fall in and out of

Medicaid eligibility1

Churning poses risks to continuity of care

11

1.  McCloskey E. A year of change: ADAPs successes and challenges implementing the Affordable Care Act. Presented at NASTAD, April 10, 2014.

Medicaid (<138% FPL)

May receive suboptimal care from a provider

without specific HIV/AIDS expertise

Possible change in treatment

regimens

Risk of poor or no transition-of-care

planning

Potential to drop out of

care entirely

Health Insurance Marketplace

CH

URN

WHAT TO WATCH AS MEDICAID EXPANSION UNFOLDS

RYAN WHITE COORDINATION WITH MEDICAID PROGRAMS

•  An important aspect of patient movement from Ryan White to Medicaid will be the provision of case management services after the transition •  In Medicaid, there is a need for nonmedical

case management and case managers knowledgeable about wraparound services1 –  Case management services are not

uniformly covered by Medicaid2

–  Ryan White programs can fill gaps in Medicaid coverage, but expect Medicaid programs’ familiarity with this to vary3,4

13

1.  Crowley JS, et al. Updating the Ryan White HIV/AIDS program for a new era: key issues and questions for the future. Kaiser Family Foundation. April 2013.

2.  National Alliance of State and Territorial AIDS Directors. Health reform issue brief. Coverage of case management services. June 2014.

3.  Center for Health Law and Policy Innovation, Harvard Law School. State health reform impact modeling project: estimating the transition of people living with HIV/AIDS to Medicaid or subsidized private health insurance through the Patient Protection and Affordable Care Act. 2013.

4.  Dalzell MD. Manag Care. 2013;22(12):12–16,25.

Ryan White 89%

Medicaid

40%

13%

Share of payers that cover 7 key case

management services2:

Benchmark Quality Health Plans

PRACTICE CONSIDERATIONS

PRACTICE CONSIDERATIONS

•  Provider shortages in Medicaid –  Not enough infectious disease specialists trained in HIV medicine1

–  Too few physicians qualified to prescribe and manage HIV drugs2

–  HIV specialists aren’t always classified as primary care physicians2,3

–  New enrollees may be automatically assigned to providers without HIV expertise2,3

•  Medicaid coverage of HIV drugs varies –  ADAP formularies cover 28 to 32 of the 32 currently available

antiretrovirals, depending on the state4

–  How does this compare to state Medicaid plans? –  Can ADAPs fill gaps in prescription drug coverage in states with lean

formularies and prescription drug limits?

15

1.  Heitz D. Schooling primary care doctors about HIV and PrEP. Healthline.com. August 25, 2014. 2.  Heitz D. Nearly 50,000 HIV patients will gain coverage under Obamacare, Medicaid. Healthline.com. February 10, 2014. 3.  Dalzell MD. Manag Care. 2013;22(12):12–16,25. 4.  Kaiser Family Foundation. AIDS Drug Assistance Programs (ADAPs). April 2014.

QUESTIONS?

Janssen Therapeutics, Division of Janssen Products, LP

Distributed by: Janssen Therapeutics, Division of Janssen Products, LP, Titusville, NJ 08560 © Janssen Therapeutics, Division of Janssen Products, LP 2015 01/15 025344-141120

THANK YOU!