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

Transcription

1 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

2 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?

3 Mapping Transitions Uninsured Lawfully present Income up to 138% FPL Uninsured Lawfully present Income % FPL Currently on Medicaid Currently on other government-sponsored insurance (e.g., Medicare, TRICARE) Currently on or have access to employerbased coverage Currently on PCIP or high risk pool Uninsured and categorically ineligible for federal programs Medicaid Subsidized private insurance through Marketplace No transition No transition If plan is affordable and comprehensive, no transition Medicaid or Marketplace coverage No transition

4 How Do I Apply for Coverage? Navigating the Marketplace Web Portal Medicaid Qualified Health Plan (QHP) 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 Federal Subsidies for Private Insurance: Premium Tax Credits Cost-sharing reductions

5 New Application Process: Simple and Streamlined 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 1 st, 2013 and runs until March 31 st, 2014

6 What Will My Coverage Look Like? Plans Sold in the Marketplaces and Medicaid Expansion Must Cover Essential Health Benefits (EHB) Preventive and wellness services Laboratory services Emergency services Hospitalization Prescription drugs Mental health and substance use disorder services Ambulatory services Maternity and newborn care Rehabilitative and habilitative services Pediatric services BUT, even with EHB requirements, there will be different plan options to choose from

7 What to Look for in Choosing a Plan 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 % FPL Cost-sharing reductions for people % FPL Check with your state s ADAP to see if ADAP can help with premiums and cost sharing

8 What to Look for in Choosing a Plan Premium Tax Credits in Action (Michael) 150% FPL (Michelle) 300% FPL Income (individual) Second Lowest Cost Silver Level Plan Premium Individual Minimum Contribution Federal Premium Tax Credit Annual Monthly Annual Monthly Annual Monthly Annual Monthly $17,235 $1, $4,500 $375 $ $57.45 $3, $ $34,470 $2, $4,500 $375 $3, $ $1, $102.11

9 Know Your Rights and Protections

10 How Will Ryan White/ADAP Coordinate with New ACA Coverage? RX MEDICAL CASE MANAGEMENT ORAL HEALTH SERVICE QHP MEDICAID RW PART B / ADAP Cost-sharing assistance LABS MENTAL HEALTH SERVICES SUBSTANCE ABUSE TREATMENT HIV PRIMARY CARE Cost-sharing assistance Cost-sharing assistance Cost-sharing assistance Cost-sharing assistance MEDICAL TRANSPORTATION Limited Coverage INPATIENT HOSPITAL SERVICES

11 Example: Case Management Coverage Private Insurance Benchmark Plan Case management Periodic phone calls to discuss appointments and assist in finding services. Ryan White Program 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).

12 Resources National Alliance of State & Territorial AIDS Directors (NASTAD), Amy Killelea, HIV Health Reform, Treatment Access Expansion Project, HIV Medicine Association, Health Care Reform Resources State Refo(ru)m, Kaiser Family Foundation, Healthcare.gov,