WHAT DOES IT MEAN FOR PEOPLE WITH HIV, THEIR PROVIDERS, AND THE RYAN WHITE PROGRAM?

Transcription

1 Health Care Reform WHAT DOES IT MEAN FOR PEOPLE WITH HIV, THEIR PROVIDERS, AND THE RYAN WHITE PROGRAM? A N N E D O N N E L L Y, JUNE 2011 H E A L T H CARE POLICY DIRECTOR P R O J E C T I N F O R M A D O N N E L L P R O J E C T I N F O R M. O R G X 2 0 8

2 Presentation Outline How Health Care Reform Affects People with HIV general information Impact on the Systems that Serve People with HIV Health Care Reform Challenges Implementation California s Bridge to Health Care Reform What You Can Do

3 Overview of Health Care Reform HOW PEOPLE WITH HIVARE A F F ECTED

4 Health Care Reform General Provisions Mandates all U.S. citizens and legal residents maintain health insurance coverage Provides subsidies to help low income people afford insurance Provides exceptions for those for whom it would be a hardship Makes significant changes in all parts of health care system Medicaid Medicare Private health insurance Elements are phased in over the next 10 years Most protections and expansion occur in 2014

5 What does it do for PLWHA? Health care reform addresses several current system failures for PLWHA Reduces discrimination by health plans due to health status Allows people with HIV to access affordable coverage Sets up new insurance requirements and protections De-links insurance and employment Covers all childless adults under Medicaid with a new national income standard of 133% FPL; removes asset test Offers federal subsidies to lower income individuals to make coverage and services more affordable; sets caps on out of pocket expenditures Creates a new minimum standard of benefits in the exchange and Medicaid expansion population Begins to close the donut hole for Medicare Part D; eventually closing it by 2020 Allows ADAP to count as TrOOP

6 A Major Expansion of Coverage Expansion through two strategies Medicaid expansion: All non-elderly with income under 133% FPL* Initial CA estimates show as many a 70% of currently uninsured people with HIV will qualify for Medi-Cal expansion State Health Insurance Exchanges: Income over 133% FPL Purchase coverage through a state regulated insurance marketplace with subsidies for lower income individuals and families Initial CA estimates show most currently uninsured people with HIV will qualify for subsidies *2011: 133% Federal Poverty Level for an individual = $14,484 yr

7 Medicaid Expansion Key Features Creates a new eligibility category for all non-elderly people with incomes < 133% FPL Eligibility based on income (no asset or disability test) 100% federal support for Medicaid expansion ; gradually decreases to 90% in 2020 Minimum benefit package for expansion population Optional state expansion with regular federal match as of April 2010 Working to allow 1115 waivers for people with HIV under easier budget neutrality conditions before 2014

8 Insurance Exchanges Key Features 2014: Insurance options for individuals with income above 133% FPL (and small group employers) State based, centralized marketplaces to purchase insurance Goal is to create more competition Better benefits package/coverage Lower costs to the consumer Tax credits, subsidies, and out of pocket spending caps will help people between 133 % FPL 400% FPL* afford insurance Reduces age, gender, pre-existing/ high health cost condition discrimination Initial estimates show about 25 30% of uninsured people with HIV will qualify for coverage and subsidies Establishes a minimum benefit requirement * 2011 FPL: 133% = $14,484; 400% = $43,560 for an individual

9 Essential Benefits Package Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

10 Medicare Program Improvements Part D Benefit General Coverage 2010: $250 rebated paid to individual who enter the coverage gap or donut hole 2011: ADAP counts towards Medicare Part D TrOOP (the expenditure that moves a person through the donut hole) 2011: 50% discount on brand name drugs while in the donut hole. Begins to close the coverage gap 2020: Coverage gap phased out for general Medicare population No expansion to new populations 2011 No cost sharing for preventative services rated A and B by the US Prevention Services Task Force (USPSTF) Covered: Targeted HIV testing & testing for pregnant women Creates a new office to better coordinate services for dually eligible individuals (Medicaid/Medicare)

11 Pre-Existing Condition Insurance Plan (PCIP) One Potential Bridge to HCR Temporary insurance option for those with pre-existing conditions In each state, some run by states, some by the federal government Must have been uninsured for at least six months and not able to get insurance Federal programs not CA just eased proof of not being able to get insurance Although costs are lower than other high risk pools they are still significant have just been lowered in many of the federal programs Federal programs not CA just dropped premium levels Out of pocket costs are capped at different levels CA is $2500 annually CA will pay premiums for PCIP coverage through CARE-HIPP PCIPs have not enrolled many people People with HIV will need support to engage in PCIPs Five states have been successful in enrolling some people with HIV in PCIPs

12 Health Care Reform and Immigrants Certain immigrant populations are completely excluded from health care reform Undocumented individuals are not eligible for coverage Medicaid Health Insurance Exchange Subsidy Legal immigrants continue to face a five year waiting period for Medicaid Some states including CA -provide coverage to this population using state dollars but services threatened by budget cuts Some exceptions including people seeking asylum, refugees and some others

13 Transitioning to New Systems Ryan White programs and support systems created a relatively seamless system of care Many people with HIV are not aware of where they get their health care coverage The transition to Medicare Part D shone a bright light on our lack of qualified navigators for people with HIV No better situation now; could get worse with cuts People with HIV will need to know where they get their current health care and what they will need to do to transition Ombudsprogram for HCR grossly underfunded and may not be able to specifically help people with HIV Will need to ensure that people get the help and support they need to access coverage, services and necessary Ryan White support

14 Summary OVERVIEW OF HEATH CARE REFORM AND HOW PEOPLE WITH HIV ARE AFFECTED

15 The Promise: Significant Expansion of Access to Care and Treatment for People with HIV Disability criteria and pre-existing condition exclusion will no longer keep people with HIV/AIDS out of coverage A majority of uninsured people with HIV will be eligible for coverage under Medicaid or the Health Insurance Exchange Estimates indicate that 70 75% of uninsured people with HIV could qualify for Medicaid in 2014 Undocumented individuals and some legal immigrants are not included in coverage under health care reform Estimates indicate that most persons eligible for coverage through the Exchange will also be eligible for additional help purchasing insurance A new minimum standard of benefits will be created in the Medicaid expansion program and the Exchange Additional beneficiary protections will be enacted

16 A Big Step Forward; Not a Perfect Solution Coverage: Coverage is not universal, no public option, statebased exchanges Certain immigrant populations are left out of health care reform entirely No mandatory dental or vision coverage Possibility of multiple benefits packages in Medicaid and continued state disparities Distinct possibility of churning or moving between plans for people near 133% FPL Reimbursement: Full federal funding for Medicaid expansion is temporary, although continues at 90% Routine HIV testing not explicitly covered Inadequate provider reimbursement not addressed Affordability Exchange subsidies, caps and tax credit could be insufficient Overall health care costs not explicitly addressed Medicare Part A, B & D costsharing still too high for some Transition & Engagement: No good systems in place Significant possibility that people at the margins of eligibility will bounce from program to program

17 Ryan White Programs SYSTEMS THAT SERVE PEOPLE LIVING WITH HIV

18 Integrating the Ryan White Care System National HIV/AIDS Strategy depends on successful HCR implementation Real coverage expansion depends on successful implementation Ryan White has funded an alternative care system for people with HIV, a model for both HIV and chronic care Excellent infrastructure, expertise, and care and treatment models have developed through the years Opportunity: To bring new models of chronic care delivery to larger systems Risk: Transition is challenging and it is possible to lose systems and infrastructure Ryan White care system will have to integrate with larger care systems Clinics will have to be able to contract, bill and interact with private and public care systems, including managed care If estimates of up to 70% of uninsured people covered by Medicaid are accurate, strategies will have to be formulated for sufficient provider reimbursement New models will have to be explored: Becoming a Federally Qualified Health Center (FQHC) Integrating with a FQHC Medical Home Models

19 The Ryan White Program Ryan White scheduled for reauthorization in 2013 If we keep health care reform: Will need to assess gaps, how to fill them, develop new systems Obvious gaps: care for undocumented, dental, vision, unaffordable out of pocket expenditures Less obvious: continuity of care for those falling in and out of systems, navigation of care systems, support for retention in care, benefits support Clinic issues: Part C and other Ryan White funded clinics Most uninsured positive people will go to Medicaid and the exchanges Staffing and infrastructure, for contracting, billing and interacting with payers Reimbursement changes, likely to receive less money under other payers Innovative ideas to have Ryan White funding supplement other funding may be important

20 Clinic Strategies Begin educating yourself and your clinic about the opportunities and challenges of health care reform Primarily Ryan White funded clinics will have to seek out other reimbursement $11 Billion over five years has been invested in community clinics or Federally Qualified Health Centers (FQHCs) cut in FY Only some clinics will qualify Less 1/3 Ryan White Part C clinics are FQHCs Planning grants went out in March 2011 Challenging criteria HRSA has been doing TA Additional reimbursement available for qualified clinics Integration and collaboration can sometimes work Medicaid is investing in Medical Home Models Increased federal reimbursement for an 8 quarter period Increased reimbursement for HIV particularly under Medicaid Better integration of HIV care into primary care

21 Health Care Reform CHALLENGES

22 Health Care Reform Challenges Some Republicans have vowed to attack and dismantle health care reform Attempt to repeal the entire legislation Passed the House; lost in the Senate Efforts to reduce or eliminate funding for portions of the bill Saw a 33% in Community Health Center (CHC) funding in FY 2011 compromise budget Prevention and Wellness Fund, Center for Medicare and Medicaid Innovation and CHC funding seemed particularly at risk Legal challenges going to the Supreme Court Challenging the individual mandate Congress right to mandate that individual purchase insurance If the individual mandate is found unconstitutional the whole legislation could be struck down Medicaid expansion illegal may not have merit

23 Health Care Reform Challenges Cont. FY 2012 budget and Deficit reduction proposals Ryan proposal: Block Grant Medicaid Privatize Medicare Voucher system Eliminate funding for coverage expansions under Health Care Reform Continue tax cuts President s proposal More balanced tax and spending cuts Preserves Medicaid, Medicare and health care reform monies Raising the debt ceiling Tying the vote to deficit reduction Federal spending cap proposals Cause deep cuts in all social programs States deficits causing program cuts; looking for relief from MOE requirements; some refusing implementation money; some threatening to pull out of Medicaid; some Governors using health care for political purposes

24 Implementation WHAT IS HAPPENING NOW

25 Implementation Biggest threat to health care reform are the upcoming elections If the Presidency and/or the Senate changes hands the coverage expansions in health care reform are endangered It is critical to implement as much of health care reform as possible and to ensure that people know how it benefits them Already enacted: Small employer tax credits Prohibition against refusing coverage for children with pre-existing conditions 1.8 M Medicare Part D beneficiaries got $250 in 2010

26 Implementation 50% discount on Medicare Part D brand name drugs in the coverage gap Reduces donut hole from about $4500 to $2100 ADAP counts toward TrOOP People up to 26 years can stay on their parents coverage End of life-time and restrictive annual limits on coverage Insurance companies can no longer do rescissions (taking away insurance when people get sick) September, 2010, no cost-sharing for many preventive services (includes at-risk HIV testing) under Medicare and new private plans Insurance companies are required to spend 80 85% of the premiums they collect on health care for beneficiaries or refund the money

27 Implementation Big upcoming issues: Essential benefits package Client transition issues Eligibility mechanisms Establishment of State Health Exchanges Alignment between Medicaid programs and health plans Proactive exchanges vs. passive exchanges Amount of regulation Information and education

28 Implementation Much implementation has already taken place Much will be a state by state story Some states moving ahead; others stalling California: Medi-Cal 1115 waiver Bridge to Health Care Reform Establishes Low Income Health Programs (LIHPs) a type of Medi-Cal expansion to cover 500,000 low income uninsured Moves all seniors and people with disabilities into mandatory managed care

29 Low Income Health Programs Medi-Cal expansion for those up to 133% FPL a couple of counties will go to 200% FPL under a coverage initiative Covers currently uninsured people including PLWH A bridge to Medi-Cal expansion in 2014 Each county has submitted an application to develop a program Oversight in guidance about payer of last resort for people with HIV and Ryan White programs SF and LA assumed that RW would continue to be payer of first resort Centers for Medicare and Medicaid appear to have disallowed this No plan for transition of people with HIV from current providers Counties may have to redo applications

30 Mandatory Medi-Cal Managed Care for Seniors and People with Disabilities Starting June 1, 2011 all seniors and people will move into mandatory Medi-Cal managed care Rolling enrollment based on birth month If a beneficiary does not choose a plan or take an action they will be defaulted into a plan Information and notification has been insufficient Many HIV providers have signed up with managed care plans some have not If an HIV positive Medi-Cal beneficiary s provider is not with managed care; should be able to file a Medical Exemption Request Can also enroll in a plan and request a continuity of care provision can continue to see provider if provider will accept payment from plan and move to contract with plan

31 Other California Implementation Establishing laws and systems that will support health care reform Health Insurance Exchange Board appointed and meeting Laws to limit premium increases; Expand patient protections; And ensure smoother transitions are moving through the Legislature

32 Defending and Implementing Health Care Reform WHAT YOU CAN DO

33 Building a Bridge to Health Care Reform State and Federal deficits and spending cuts taking a terrible toll on HIV care and services Over 8000 people on ADAP waiting lists FL ADAP ran out of money entirely and may do again Many states cutting eligibility for ADAP forcing people off the program Clinics at maximum capacity Medicaids throughout the country instituting cuts, benefit limits and mandatory cost sharing CA cut most optional services Budget contains mandatory cost sharing; Physician visit limitations; And a lock in to managed care plans It s essential that we start planning how to get through to health care reform Take advantage of Pre-existing Condition Insurance Pools ADAP will pay premiums and drug co-pays; no other costs Low Income Health Programs

34 Defending Health Care Reform Educate ourselves and each other about health care reform Help people with HIV to begin to understand their health care benefits Defend health care reform Join HIV Health Care Access Work Group, Families USA, Health Care for All Now Understand deficit reduction and debt ceiling increase efforts - Defend Medicaid and Medicare against cuts Get involved in state level implementation advocacy Begin talking to your co-workers, clinic administrators about integration into larger systems - FQHCs, medical home models, Medi-Cal managed care in CA

35 Health Care Reform Access to affordable quality health care is a part of the American dream. We don t believe that people should have to hope against hope that they will stay healthy. The time for fighting the battles is past; we need to move forward. President Obama

36 Resources Center for Medicare Advocacy FamiliesUSA Kaiser Family Foundation Treatment Access Expansion Project HealthReform.gov Department of Health and Human Services Center for Consumer Information and Insurance Oversight Policy analysis and beneficiary information on the new law s impact on Medicare, including Part D Summaries, fact sheets, issue briefs; Join listserv for information updates, including periodic national conference calls on health reform topics Summaries and implementation timeline; Fact sheets on Part D, exchanges and subsidies Analysis of HIV-related provisions, including presentations Administration website with information on the new law, including an ongoing Q&A forum and state-specific information Responsible for implementation of various elements of health care reform. Also administers the federal high risk pool