Outreach and Enrollment Assistance to People Living with HIV: Lessons from the First Year and Looking Ahead

Transcription

1 Outreach and Enrollment Assistance to People Living with HIV: Lessons from the First Year and Looking Ahead Nov. 5, 2014 Download the slides & materials at Start the conversation on Twitter. Use #EnrollmentYR2, #ACA and #HIV.

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6 Check out HIVHealthReform.org

7 Today s Agenda 1. Big Picture Lessons Learned from 2014: Moving Forward - Malinda Ellwood, JD, Center for Health Law & Policy Innovation, Harvard Law School 2. Affordable Care Enrollment (ACE) TA Center - Stewart Landers, Health Services Director, Boston, John Snow, Inc. 3. Updated Resources - Jennifer Kates, Vice President and Director of Global Health & HIV Policy, Kaiser Family Foundation 4. ACA Enrollment and Ryan White Program Coordination - Amy Killelea, JD, Associate Director, Health Care Access, NASTAD 5. Open Enrollment as a Navigator - J. Lauren Banks, Chief Policy and Advocacy Officer, AIDS Alabama

8 Big Picture Lessons Learned from 2014: Moving Forward Malinda Ellwood, JD Clinical Instructor of Law Center for Health Law and Policy Innovation Harvard Law School

9 Change in Uninsured Americans, : AN EXTRAORDINARY ACCOMPLISHMENT Source: Kevin Quealy and Margot Sanger-Katz, Obama s Health Law: Who Was Helped Most, New York Times,

10 But We Have Our Work Cut Out For Us: Who Remained Uninsured in 2014 Source: Kevin Quealy and Margot Sanger-Katz, Obama s Health Law: Who Was Helped Most, New York Times,

11 How Do We Know Where We Are? Because you SPEAK UP! With support from the M A C AIDS Fund, a team of national and state partners has established SPEAK UP to monitor, assess and document ACA implementation success and barriers to HIV care Through SPEAK UP we see patterns of discrimination emerging that need to be addressed, educate state and federal officials about what s happening on the ground, advocate for change, and report back to the community Ongoing monitoring and documentation is critical to help inform and shape state and federal policy to ensure the needs of people living with HIV are addressed as the ACA is implemented To SPEAK UP!, visit:

12 Lessons Learned from 2014: Enrollment and Coverage Barriers Lack of transparency was often a barrier to choosing the right plan Some plans had inadequate formularies, for instance, failing to cover all single-tablet regimens Many plans placed HIV medications on formulary tiers with very high levels of cost-sharing Increased placement of HIV medications on tiers requiring specialty or mail-order pharmacies, and/or excessive prior authorization Some difficulties with ADAP/Ryan White and QHP coordination

13 Moving Forward to 2015: What Advocates Can do The good news: All plans are required to provide: direct links from the marketplace to their formularies and provider networks; and make clear which formularies and networks apply to particular QHPs What advocates can do: Provide information on insurance 101, particularly on cost-sharing terms and what they mean Very important to prepare as much as possible in advance: form coalitions and reach out to other community partners to assist each other in advanced plan review o Remember, you have until Dec. 15 to select a plan to be enrolled by Jan. 1, and open enrollment extends to Feb. 15 Ensure consumers/clients are aware of what kinds of information to look for when selecting a QHP: 1. Check with providers to see what networks they re in 2. Bring lists of medications and ensure they re covered 3. Check cost-sharing requirements 4. Check for any mail-order, specialty pharmacy, and PA requirements o CHLPI QHP assessment tool: Share information and best practices!

14 Other Avenues/Resources for Advocates Don t forget about the right to appeal adverse enrollment and coverage decisions! File grievances with insurance companies In many states, you can also contact a Consumer Assistance Program (CAP) for help (see Grants/) Contact your state s ombudsmen programs for issues with Medicaid (varies by state) or Medicare (see

15 The Big Picture: Changing the Landscape Filing complaints with state departments of insurance (DOIs) regarding transparency or coverage concerns Community partners (AIDS Foundation of Chicago, AIDS Legal Council of Chicago, Jenner & Block) sent a complaint to the IL DOI which included specific examples of harmful coverage exclusions, burdensome prior authorization processes, and other practices in IL health plans The IL DOI responded with a bulletin to insurers suggesting that plans which fail to cover all HIV drugs as recommended by HHS, and/or plans who institute burdensome and redundant prior authorization requirements may be found to be discriminatory Filing complaints with the Office of Civil Rights (OCR) (federal) In Florida, the AIDS Institute (AI) partnered with the National Health Law Program (NHeLP) to filed a complaint with OCR in regards to several FL plans that placed ALL HIV medications on the highest cost-sharing tiers Filing complaints in courts In LA, Lambda Legal brought a successful lawsuit alleging discrimination by plans who had stopped accepting payments from Ryan White and ADAPs o In response, CMS also released interim final regulations requiring all QHPs to accept third-party payments from Ryan White and other government programs In CA, a lawsuit was brought alleging discrimination by health plans that required individuals living with HIV to obtain their medications through mail order pharmacies As a result the insurance carriers, including United, must offer all individuals living with HIV the option to opt-out of mail order pharmacy requirements o For more information, visit: Advocacy at the federal AND state levels We continue to share your examples from Speak Up and to advocate for federal policy change The NV DOI has proposed a regulation that would limit the ability of plans to reclassify drugs in in a formulary Many states have also implemented cost-sharing protections

16 Affordable Care Enrollment (ACE) TA Center Stewart Landers Health Services Director, Boston John Snow, Inc.

17 Building capacity for outreach and enrollment Needs Assessment: What grantees say they need Best Practices Assessment: What the field says is needed Gap Analysis: What is relevant/ works for PLWH of Color Responsive and relevant O&E support for RWHAP grantees and providers Evaluation & CQI

18 ACE TA Center Objectives Provide tools and resources to help providers (grantees and subgrantees) enroll clients of color, always considering cultural and historical barriers to enrollment Build grantee understanding of the need for culturally competent O&E strategies Provide technical assistance and training to promote the use of these tools and resources Enhance the capacity of RWHAP Part A and B grantees to support subgrantees

19 Grantee and Provider Needs Assessment

20 Methodology 30-minute Needs Assessment tool collected information on: Background of respondent; Understanding of policy requirements; Among Part A/B grantees, providing support to RWHAP-funded providers; Among direct service providers outreach and enrollment (O&E) support; post-enrollment and re-enrollment support; Training and technical assistance (T/TA) needs for O&E. Piloted and translated into Spanish Disseminated online to RWHAP grantees and subgrantees Data cleaned, analyzed and report prepared Overall and stratified results are presented

21 Assessment responses by state Total analytic sample included 231 respondents from 45 states, DC, Puerto Rico and USVI

22 Needs assessment findings While there were many similarities across grantees and providers (including across RWHAP Parts), challenges varied by Medicaid expansion status insurance exchange type enrollment capacity TA and training needs will be different for grantees and providers depending on these variations.

23 Top O&E challenges* related to serving minority clients DIRECT SERVICE PROVIDERS (n=172) HEALTH DEPARTMENTS (that do not provide direct services) (n=25) Lack of information/knowledge among clients 73% 60% Ineligibility due to immigration status 58% 28% Fears related to immigration status (e.g. affecting path to citizenship) Previous negative experiences with insurance, making clients distrustful/nervous about enrollment Providers lack of familiarity with health insurance coverage/aca 46% 40% 45% 24% 41% 36% Language barriers 39% 24% Limited funding 37% 16% Other 16% 16% * Significant variation by Medicaid expansion status, insurance exchange type, and enrollment capacity.

24 FINDING #1: Limited knowledge & experience Many direct service providers faced general O&E challenges related to lack of knowledge of new coverage options. Specific T/TA needs vary depending on local circumstances, including: whether a state has chosen to expand Medicaid the type of marketplace a state is using state-specific decisions about how ACA information may be communicated

25 FINDING #2: Barriers to accessing care RWHAP providers are working with minority clients who have historically faced barriers to accessing care and who may not be comfortable enrolling in new ACA coverage options. Clients are particularly concerned about plan affordability, as well as the possibility of needing to change providers. Both O&E capacity and cultural competency are critical to enrolling and retaining minority RWHAP clients in ACA coverage options.

26 FINDING #3: Communication and coordination RWHAP grantees and providers want more local guidance about policies and best practices. Gaps in coordination may have implications for how clients experience care. Communication and coordination needs include: policy guidance from state and local health departments information about state and federal ACA policies training on how to assess coverage options for clients collaboration between state RWHAP and Medicaid programs

27 Training & TA Strategies

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29 Cultural competency WE UNDERSTAND that your clients are diverse in regards to their race, ethnicity, native language, sexual orientation and gender identity. how important it is that your clients have access to continuous, quality, affordable care. your clients may have concerns about obtaining new health insurance.. WE ARE COMMITTED to providing culturally appropriate tools and resources that support your outreach and enrollment efforts and address many of the issues faced by RWHAP clients, particularly clients of color.

30 Resources, Tips, & Tools

31 Enrollment steps

32 Resources, Tips, and Tools for Enrolling RWHAP Clients in Coverage

33 Eligibility Decision Tree

34 Health Care Plan Selection Worksheet

35 Fact Sheet: Topics to Consider When Helping People Living With HIV to Enroll in Health Care Coverage

36 Common Questions & Suggested Responses for Engaging Clients in Health Coverage (English)

37 Common Questions & Suggested Responses for Engaging Clients in Health Coverage (Spanish)

38 Plain Language Quick Reference Guide Plain Language Quick Reference Guide (English) 38

39 Plain Language Quick Reference Guide Plain Language Plain Language Quick Reference Quick Reference Guide (Spanish) Guide 39

40 Special Enrollment Periods Fact Fact Sheet

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42 Training & TA: Upcoming Products and Activities

43 Future training & TA products Job aids for staff Organizational level resources Remote and in-person consultation to organizations and jurisdictions Webinars Web-based and in-person training resources

44 Mark your calendar! Wednesday 11/12 at 3:30 PM (ET): Plan renewals and open enrollment for 2015 Monday 11/17 at 3:00 PM (ET): Managing the coverage gap - best practices in states not expanding Medicaid Register at targethiv.org/ace

45 Coming soon New ACE TA Center resources, including: Enrollment tracking worksheet Flow chart for renewals Tax credits and cost sharing reductions simplified Best practices for organizations

46 BISOLA STEWART targethiv.org/ace Sign up for our mailing list, download tools and resources, and more MIRA TAJAN Any questions? Contact us at

47 Updated Resources Jennifer Kates Vice President and Director of Global Health & HIV Policy Kaiser Family Foundation

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49 Health Coverage, HIV & You Portal Updated and newly named Health Coverage, HIV & You consumer web portal helps PLWH navigate the Affordable Care Act (ACA) Features of the portal include: New Five Most Important Things for People with HIV to Know About the Affordable Care Act Find Your Story: Explains how someone with HIV may be affected by the ACA based on their current insurance situation Common Questions: Addresses 75+ questions about the ACA and its impact on PLWH State-specific information (for all 50 states + D.C.): Covers health insurance marketplaces and financial assistance, Medicaid, the Ryan White HIV/AIDS Program and ADAP, and other relevant HIV resources Other tools: Includes links to the Foundation s animated video explaining how to get ready for the ACA and its subsidy calculator, as well as links to other resources greaterthan.org/healthcoverage

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52 ACA Enrollment and Ryan White Program Coordination Amy Killelea, JD Associate Director, Health Care Access NASTAD

53 Qualified Health Plan Enrollment: Key Dates and Deadlines 2014 Benefit Year Oct. Nov. Dec Benefit Year Jan. Feb. Mar. November 15, 2014 Open enrollment for the 2015 benefit year begins December 15, 2014 Date by which individuals must enroll in a plan for Jan. 1 effective date January 1, 2015 First day of the 2015 benefit year earliest possible coverage effective date for 2015 February 15, 2015 Open enrollment for the 2015 benefit year ends Medicaid CONTINUOUS ENROLLMENT

54 Qualified Health Plan Enrollment: Potential Challenges and Strategies Potential Challenges Participation in ACA enrollment may be limited or prohibited by state employees Coordination of payment between ADAP and plans has been difficult Coordination of ADAP administration with tax credit reconciliation is complex Plan coverage and cost may change for 2015 Strategies Programs worked with community organizations and coalitions to coordinate client education, and enrollment efforts Programs cultivated relationships with trusted contacts within insurance companies Programs contracted out payment duties Programs required clients to take full amount of tax credit in advance and to report income changes Programs are beginning client education around tax filing and reconciliation Programs are assessing plan options and ensuring that clients provide Marketplace with updated income information

55 ADAP/Part B Programs Currently Purchasing Qualified Health Plans (QHPs) for Clients (June 2014) VT WA ND NY MT MN OR WI SD ID MI WY PA NE IA OH NV IN IL UT WV CO VA KS MO KY CA NC TN OK AZ AR SC NM GA MS AL AK TX LA FL HI ADAP purchasing QHPs (premiums, Rx co-pays, or deductibles) ADAP piloting QHP purchase NH ME DE MD CT NJ DC MA RI Several states that did not have statewide insurance purchasing programs in 2014 are planning to roll out plans for 2015; check with your state ADAP! ADAP not currently purchasing QHPs (most are planning)

56 Assessing and Filling Gaps in Affordability Mike (150% FPL) Mary (300% FPL) Income (monthly) Second Lowest Cost Silver Premium (monthly) Individual Minimum Contribution (monthly) Federal Premium Tax Credit (monthly) $1, $375 $57.45 $ $2, $375 $ $ OOP Costs for QHP Coverage Medical visit $25 ARVs Outpatient mental health visit OOP annual cap = ~$2,100-$6,300 30% coinsurance $25 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?

57 Addressing the Medicaid Gap in Non-Expansion States 68% of ADAP clients in non-medicaid expansion states have an income below 138% FPL To help fill the gap Ryan White Programs are: Purchasing insurance for those in the Medicaid Gap Providing safety net for those who cannot afford insurance or who are not otherwise eligible

58 HRSA/HAB ACA Policies 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 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 Ryan White Program funds may be used to cover services not covered or inadequately covered by public and private insurance HRSA is considering allowing ADAP insurance purchasing programs to cover client tax liabilities associated with an overpayment of the premium tax credit

59 Vigorously Pursuing Vigorously Pursuing Best Practices Implement client eligibility screening policy Document client contact Require attestation if client does not enroll in coverage Require client to accept full premium tax credit amount in advance and to acknowledge need to report changes in income to the Marketplace

60 Resources National Alliance of State & Territorial AIDS Directors (NASTAD), Amy Killelea, Xavior Robinson, HIV Health Reform, Treatment Access Expansion Project, HIV Medicine Association, HRSA/HAB ACA and Ryan White Resources, Health Care Reform Resources Center on Budget and Policy Priorities, Beyond the Basics, State Refo(ru)m, Kaiser Family Foundation, Healthcare.gov,

61 Open Enrollment as a Navigator J. Lauren Banks Chief Policy and Advocacy Officer AIDS Alabama

62 A program to enroll Alabamians in the Health Insurance Marketplace, Medicaid, and CHIP

63 Our Model Partner with six other AIDS Service Organizations around Alabama. Partner with one housing organization. Serve as state lead for Enroll America. Employ: Full-Time Project Coordinator 5 Full-Time Navigators 4 Part-Time Navigators Community: Over 100 Volunteers Educational Events at Clinics, Churches, Clubs, Organizations Enroll at Libraries Call-In on local NBC channel

64 Outcomes 97,870 Alabamians Enrolled in Plan through Marketplace during open-enrollment 7,500 Assisted by Enroll Alabama Thousands reached through presentations, community events, and more.

65 Lessons Learned Only hire full-time navigators. Work load is too hard otherwise. Create a central toll-free number. Break down the components. Saying Obamacare or ACA isn t always effective. Set aside at least one hour for every enrollment. Have snacks, children s toys, books, comfortable seating. Be knowledgeable about Medicare, Medicaid, and CHIP. Be able to explain Medicaid Expansion.

66 Andrew s Story Because of the ACA and the Health Insurance Marketplace, And rew was able to get health insurance for the first time since his HIV diagnosis.

67 Questions? Ask your questions using the webinar chat feature. If we don t get to your question it will be logged and we ll do our best to follow up!

68 AND DON T FORGET TO SPEAK UP! With support from the M A C AIDS Fund, a team of national and state partners has established SPEAK UP to monitor, assess and document ACA implementation success and barriers to HIV care Through SPEAK UP we see patterns of discrimination emerging that need to be addressed, educate state and federal officials about what s happening on the ground, advocate for change, and report back to the community Monitoring and documentation is critical to help inform and shape state and federal policy to ensure the needs of people living with HIV are addressed as the ACA is implemented To SPEAK UP!, visit: