HIV/AIDS Care in a Changing Healthcare Landscape A Resource for Allied Health Professionals and Their Clients

Transcription

1 HIV/AIDS Care in a Changing Healthcare Landscape A Resource for Allied Health Professionals and Their Clients Introduction Landscape Overview Talking to Clients Resources

2 Table of Contents 3 Introduction: What You need to Know About the affordable Care Act 7 Section 1: Landscape Overview Meet the Marketplace Medicaid Expansion the ryan White HIV Program 18 Section 2: Talking to Clients Key Questions for your Clients Discussing Coverage with your clients flow chart Steps to Enroll for health Coverage 24 Section 3: Resources General Reference Sites For People Living with HIV and their Caregivers For Health Professionals For Community-Based organizations Timeline Glossary Bibliography References Introduction Landscape Overview Talking to Clients Resources 1

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4 Introduction: What You Need to Know About the Affordable Care Act On January 1, 2014, expanded health insurance under the Patient Protection and Affordable Care Act (PPACA) also known as the Affordable Care Act (ACA), or more simply, healthcare reform will go into effect. As a healthcare professional who cares for people living with HIV, it is beneficial to know how this law will affect your clients. Open enrollment begins October 1, 2013 and ends March 31, Almost two thirds of the more than one million 1 Americans living with HIV do not receive regular medical care, which jeopardizes their health and the public health. 2 Healthcare reform is designed to give people better access to care, but the transition to health coverage under the new law is likely to be challenging. Your guidance will be important to help your clients enroll in appropriate medical coverage so that there are no gaps in their medical care. It will be important for you to review your clients current health insurance status to understand if they need to move into the new system. In this booklet you will find: How healthcare reform will impact people living with HIV Health insurance options for your clients, including: -- Marketplaces, where individuals may browse and choose a health insurance plan -- Medicaid expansion, which offers new or enhanced health insurance to the HIV community -- Ryan White programs, which may be able to fill gaps in medical coverage for your clients Discussion guide and key questions to ask your clients to help them enroll in health insurance Tools and resources to help guide your clients to understand coverage options available for them Introduction Landscape Overview Talking to Clients Resources 3

5 I don t have health insurance that fulfills the individual mandate. What are my options? How Does Healthcare Reform Affect People Living With HIV? Healthcare reform is expected to help people living with HIV obtain health insurance, which may result in an opportunity for more complete care that can address other health needs in addition to HIV. The law is especially important to your clients because it: Guarantees that health insurance companies can no longer deny coverage because they have preexisting medical conditions 3 Assures a fair price for health insurance premiums 4 Includes essential health benefits (EHB), which provide comprehensive health services across 10 key categories 5 Prohibits insurance companies from placing an annual dollar limit on health insurance coverage, 6 which has been a hurdle to medical care for some individuals living with HIV Extends parents health insurance coverage to dependent children up to age

6 Under healthcare reform, many people must now buy health insurance or pay a tax penalty and the tax penalty will increase with time. This new requirement to have health insurance is often called the individual mandate. If your clients currently do not have health insurance that fulfills the individual mandate, they have these options: Enroll in Medicaid coverage. Under healthcare reform, some states may be expanding their Medicaid programs. That means more people living in those states may now qualify for Medicaid. Purchase health insurance through the Marketplace. (Find more details on page 7.) Rely on safety net programs such as Ryan White and federally qualified health centers to continue to supplement their HIV care and treatment. How Healthcare Reform May Help People Living With HIV In 2012, the Centers for Disease Control and Prevention (CDC) 8 found that just 25 percent of the 1.1 million Americans living with HIV have their virus under control. The CDC found that African Americans and young people living with HIV were least likely to receive ongoing medical care, including antiretroviral drugs that can control the HIV virus. Healthcare reform is poised to expand insurance coverage and therefore access to medical care for millions of people including those living with HIV. Coordinated care models will expand access to comprehensive medical care, including treatment of health conditions that your clients may have in addition to HIV. Percent of all people with HIV 82% Overall: Of the 1.1 million Americans living with HIV, only 25 percent are virally suppressed. 66% 37% Diagnosed Linked to Care Retained in Care 33% Prescribed Antiretroviral Therapy 25% Virally Suppressed Introduction Landscape Overview Talking to Clients Resources Source: Adapted from CDC HIV in the United States The Stages of Care July

7 6 Which states have Marketplaces and how do my clients enroll?

8 SECTION 1: Landscape Overview Meet the Marketplace The Marketplace (also known as a Health Insurance Exchange) is a series of online sites designed to make buying health insurance easy and affordable for individuals, families and small businesses. Every health insurance plan in the Marketplace offers basic comprehensive coverage. 9 Your clients can begin enrolling in the Marketplace on October 1, However, health insurance bought through the Marketplace doesn t take effect until January 1, The Marketplace allows consumers to: Compare private health insurance plans Ask questions about health insurance coverage Learn which health insurance options they are eligible for Find the insurance plan that best fits their needs and budget How Many Marketplaces Exist? PLAN COMPARISONS TYPE OF COVERAGE ELIGIBILITY BEST FIT Healthcare reform authorized all states to establish their own Marketplaces. Sixteen states (CA, CO, CT, HI, ID, KY, MA, MD, MN, NM, NV, NY, OR, RI, VT, and WA) and the District of Columbia have now set up Marketplaces. That means residents of these states (and the District of Columbia) can access their Marketplace online through their state s Marketplace website. What About My Clients Who Live in a State Without Its Own Marketplace? Residents of states that don t have their own Marketplace can find health insurance at the federal Marketplace established by the U.S. Department of Health and Human Services, at 10 Introduction Landscape Overview Talking to Clients Resources 7

9 Who Does the Marketplace Serve? The Marketplace serves individuals and families who do not qualify for Medicaid benefits, and who are not currently insured by either private insurance or covered by insurance offered by their employer. Individuals and families with annual incomes between 100 and 400 percent of the Federal Poverty Level may be eligible for tax credits to help pay for insurance purchased through the Marketplace. 11 Those whose annual incomes are between 100 and 250 percent of the Federal Poverty Level may be eligible for lower out-of-pocket expenses. 12 It will be important for you to review your clients health insurance status to understand if they may need to move into the Marketplaces. How Do My Clients Enroll? As of October 1, 2013, individuals can enroll at the federally facilitated Marketplace website, found online at For those whose states offer a state-based Marketplace, they will be redirected from this site to enroll online at their state Marketplace website. Those state websites are also listed to the right. Others can enroll at the federally facilitated Marketplace website, found online at Those without Internet access can also enroll by calling the toll-free number , 24 hours a day, seven days a week. TTY users call Paper applications can also be requested. To apply in person, your clients can visit where they can search by city and state, or by zip code, to find local organizations that will help with applications. They can also find information on non-english language support, Medicaid or CHIP, and the Small Business Health Options Program (SHOP). Your clients should know that open enrollment ends March 31, What Information Is Needed to Enroll in the Marketplace? Before enrolling in the Marketplace, your clients must know: If their employer will offer health insurance for 2014 Basic information about their household income (a W-2 form, current pay stub, tax return) Information about their budget to determine which health plans are affordable 13 8

10 Marketplace Websites Residents of 16 states and the District of Columbia can access their state s Marketplaces at the following websites: California: Covered California Colorado: Connect for Health Colorado Connecticut: Access Health CT District of Columbia: DC Health Link Hawaii: Hawaii Health Connector Idaho: Your Health Idaho Kentucky: Kentucky s Healthcare Connection (Kynect) Maryland: Maryland Health Connection Massachusetts: Health Connector Minnesota: MNsure Nevada: Nevada Health Link New Mexico: New Mexico Insurance Exchange New York: New York State of Health Oregon: Cover Oregon Rhode Island: HealthSource RI Vermont: Vermont Health Connect Washington: Washington Healthplanfinder 9 What if my state doesn t have a Marketplace? Those living in states without a Marketplace can access the federal Health Insurance Marketplace at Introduction Landscape Overview Talking to Clients Resources

11 Marketplace Last date to sign up enrollment begins for coverage that will Open enrollment for 2014 coverage begin on Jan. 1, 2014 ends for 2014 Oct. 1, 2013 Dec. 15, 2013 Mar. 31, 2014 Jan. 1, 2014 Health coverage starts Essential Health Benefits Health insurance plans sold through the Marketplace must ensure that Essential Health Benefits are provided with no coverage limit. Essential Health Benefits cover a wide range of basic health services, from preventive care, office visits, lab tests and prescriptions to emergency services, hospitalization, rehabilitation care and mental health and substance abuse treatment. Individual Mandate Individual mandate refers to a new federal regulation that requires people without job-based health benefits or public coverage (such as Medicaid or Medicare) to purchase health insurance. Tax penalties will be imposed on individuals who do not purchase coverage. The tax penalties will equal either 1 percent of the individual s annual taxable income or a flat dollar amount, depending on which is greater. The flat dollar penalties start at $95 in 2014, and rise to 2 percent or $325 in 2015 and to 2.5 percent or $695 in Exceptions to the individual mandate may be made for those with a very low income or certain religious beliefs. Tax Credits and Subsidies (Lower Payments) Tax credits can help low-income individuals and families purchase coverage in the Marketplace by lowering the total cost of health insurance. Those whose annual incomes are between 100 and 400 percent of the Federal Poverty Level (FPL) and are not eligible for Medicaid expansion may qualify for tax credits. Tax credits can ease monthly cash flow, because they can be paid in advance to insurance companies to reduce health insurance premiums. Tax credits are only available to help purchase health insurance plans offered through the Marketplace. Those whose annual incomes are between 100 and 250 percent of the FPL may be eligible for lower out-of-pocket expenses

12 Medicaid Expansion Starting on January 1, 2014, many states will determine an individual s eligibility for Medicaid based on a common income threshold, which will give eight million uninsured Americans a new option for health insurance. By 2016, Medicaid is expected to cover up to 11 million people, assuming all states eventually agree to participate in Medicaid expansion. 14 Who Qualifies for Medicaid? 15 Before healthcare reform, Medicaid was generally limited to disabled adults and low-income parents, children and pregnant women. Under the new Medicaid expansion that is taking place in many states, U.S. citizens and legal immigrants with incomes less than 138 percent of the Federal Poverty Level (FPL) qualify. For example, an individual earning less than $15,856 will be eligible for Medicaid, as will a family of four earning less than $32, Table 1 can help determine if a client qualifies based on income and family size. What Does Medicaid Expansion Mean for People Living With HIV? For those living in Medicaid expansion states, this shift will mean a change in how medical care is delivered. Currently, 70 percent of uninsured people living with HIV receive care through the Ryan White HIV Program, which includes the AIDS Drug Assistance Program (ADAP). States that participate in Medicaid expansion will be able to transfer many of these clients, as well as others now on waiting lists for these programs, to more comprehensive medical coverage provided by Medicaid. What States Are Expanding Medicaid? If your state is expanding its Medicaid program effective January 1, 2014, your clients may qualify for Medicaid if they: 4 Earn less than 138% of FPL 4 Are between years of age 4 Are not eligible for Medicare TABLE 1 Household Size 138% 1 $15,856 2 $21,404 3 $26,951 4 $32,499 5 $38,047 6 $43,594 7 $49,142 8 $54,689 For each additional person, add $5,548 Source: Adapted from ASPE Federal Poverty Guidelines January 2013 Many states have made decisions about Medicaid expansion, but some are still deciding what to do. The Kaiser Family Foundation is tracking these decisions and posts regular updates on its website 17: Introduction Landscape Overview Talking to Clients Resources 11

13 How Do Clients Enroll in Medicaid? 18 On October 1, 2013, your clients will be able to apply using one application. They will find this application either on their state s Marketplace, or if their state doesn t have a Marketplace, at the federal Marketplace. If it appears that an individual or family is eligible for Medicaid, the Marketplace will send the application to the local Medicaid agency. How Do Clients Transition to Medicaid? 19 Most people eligible for Medicaid will need to choose a primary care provider who accepts Medicaid payment coverage. Gaps in medical care could occur when your clients need to change providers. Help them be alert to: Providers without specific HIV expertise Possible change in medical treatment regimens Temptation to drop out of care because of the challenges involved in navigating a new medical system Reviewing your clients current health insurance status may help you understand their Medicaid eligiblity under expansion. 12

14 What Happens to My Clients if Their State Does Not Expand Medicaid? 20 Those who earn more than 100 percent of the Federal Poverty Level can buy health insurance through the Marketplace, and may qualify for reduced premiums and lower out-of-pocket costs, based on income and family size. Clients who earn less than 100 percent of the Federal Poverty Level are still eligible to buy health insurance through the Marketplace, but they will not qualify for reduced premiums. They will need to pay full price for health insurance. If this is unaffordable, they may opt out of buying health insurance. No penalty fees will apply if they choose not to purchase health insurance. Community health centers are an option for residents of states without Medicaid expansion. Healthcare reform expands funding to these community health centers, which provide primary care for millions of Americans. To find a local community health centers near you, visit: Safety net programs, such as the Ryan White Program, are another way to help fill gaps for uninsured people living with HIV. Most people eligible for Medicaid will need to choose a primary care provider who accepts Medicaid payment coverage. What Is the Difference Between Medicare and Medicaid? 21 Medicare primarily serves the disabled and people aged 65 years and older regardless of income. It operates under the federal government and has consistent national guidelines. Medicaid serves the disabled and low-income people of all ages. Medicaid is administered by state and local governments. Clients either pay a small co-payment or no cost for medical expenses. Medicaid varies widely from state to state. 13 How Do My Clients Enroll in Medicaid? Your clients will need to document their household income by showing a W-2 form, current pay stubs, or their tax return. 22 Applications can be submitted: In person at local Medicaid agencies Online at the state Marketplace s website beginning Oct. 1, 2013 By phone in the state Marketplace beginning Oct. 1, 2013 Introduction Landscape Overview Talking to Clients Resources

15 The Ryan White HIV Program More than half a million people living with HIV receive medical care annually through the Ryan White HIV Program. 23 Called wraparound coverage, 24 Ryan White funds primary medical care and essential support service, including Ryan White clinics and the AIDS Drug Assistant Program (ADAP). 25 The AIDS Drug Assistance Program ADAP is part of the Ryan White Program. It provides HIV-related prescription medications, including antiretroviral drugs, to those with limited or no drug coverage. Up to 77,000 uninsured people living with HIV may qualify for Marketplace subsidies. Exact figures depend on how many states expand Medicaid. 26 More than half of those served by the ADAP may qualify for Medicaid. 27 What Happens to the Ryan White Program Under Healthcare Reform? Under healthcare reform, millions of people living with HIV who depend on Ryan White Programs, will either become eligible for Medicaid or be able to buy lower-cost health insurance in state or federal Marketplaces. 28 This shift may enable Ryan White Programs to refocus resources to: Contribute to out-of-pocket cost sharing and co-pays Support health services, including dental, that some health insurance plans may not cover Reimburse HIV providers for services Offer care, treatment and services to those not eligible for Medicaid or Medicare or to purchase health insurance in the Marketplace Each state sets its own rules for the Ryan White Program. So depending on where you live, some clients will still be eligible, while others will no longer qualify. You must know and understand which clients are eligible to move from Ryan White into Medicaid or the Marketplace. Ryan White is the payer of last resort, so those who qualify are required to move and you must document your efforts to assist them in making this happen. 14

16 Will Ryan White clinics change under healthcare reform? Introduction Landscape Overview Talking to Clients Resources 15

17 16 Will my clients still be eligible for the Ryan White Program?

18 How Will Healthcare Reform Affect AIDS Drug Assistance Program Benefits? Under healthcare reform, AIDS Drug Assistance Program (ADAP) benefits will vary from state to state. States that don t expand Medicaid may have waiting lists and caps on assistance. ADAP assistance may be available to low-income clients who get commercial coverage through Marketplaces, to provide help with premiums and co-payments. Depending on the state, ADAP may also help Marketplace or Medicaid enrollees get antiretroviral drugs that are not included in their health insurance plan s formulary. Will Ryan White Clinics Change Under Healthcare Reform? Yes. Until now, Ryan White clinics have been funded through grants. Under healthcare reform, Ryan White clinics must negotiate and contract directly with Medicaid programs and insurance plans. Reimbursement rates will vary and may not be sufficient to maintain the same quality of care. Because of this, some Ryan White clinics are working to become federally qualified health centers (FQHC), which would likely allow them to continue to receive funding through grants. These clinics may provide a safety net if there is a shortage of healthcare providers who accept new Medicaid clients. 29 Some people living with HIV still won t be eligible for insurance in the Marketplace or qualify for Medicaid. They will need to rely on Ryan White clinics for healthcare coverage. These populations include: Low-income residents whose states do not expand Medicaid and who are unable to pay for health insurance Undocumented immigrants, who are not eligible to buy health insurance through Marketplaces Legal immigrants who are subject to a five-year waiting period for Medicaid How Can I Help My Clients Receive Support From the Ryan White Program? First, determine if your client is eligible for coverage in the Marketplace or through Medicaid or Medicare. If their annual income is below 100 percent of the Federal Poverty Level, it may be necessary for them to use Ryan White services. Investigate the availability of Ryan White services in your area, particularly case management services, which can assist the client in navigating the healthcare environment. If their annual income is below 100 percent of the Federal Poverty Level, and their state is not expanding Medicaid, it may be necessary for them to use Ryan White services. To find a local Ryan White Program, visit Health Resources and Service s Administration s locator tool: Ryan White providers and clinics may need to join the state/federal Marketplace and Medicaid, so that the people living with HIV may access them under the new networks. Ryan White differs from state to state. Ask about your state requirements. Find out how to be included in the billing networks, referral networks, and care networks for your state s exchanges and state Medicaid program. Introduction Landscape Overview Talking to Clients Resources 17

19 The following questions are also provided in a tear-off pad at the back of this booklet, for distribution to your clients. SECTION 2: Talking to Clients KEY QUESTIONS FOR CLIENTS The following is a list of key questions and things to think about when selecting health insurance 30, 31 that best meets your needs under healthcare reform. Are you a U.S. citizen or legal resident? Can you prove it? If not, you can t buy health insurance in the Marketplace, and you do not qualify for Medicaid/ Medicare. You should consider getting care through the Ryan White Program. If you are a U.S. citizen or legal resident, you must have health insurance. The following link will provide more information on immigration statuses that qualify for Marketplace coverage: Do you have Medicaid or Medicare? If yes, and your eligibility remains the same, you do not need to apply for new health insurance through Medicaid or Medicare. You cannot buy insurance in the Marketplace. Does your employer or your spouse s employer offer affordable health insurance (that costs less than 9.5% of your household income to cover yourself) with adequate benefits defined by the Affordable Care Act? If so, you are covered and are not required to buy insurance in the Marketplace. If not, you may be qualified for Medicaid or required to buy insurance in the Marketplace. What Marketplace should you use to find health insurance? Has your state set up its own Marketplace, or will you use the federal government s Marketplace? Visit to find out. What is your annual household income? Based on the number of people that live in your household and your annual income, you may be eligible for cost savings in the Marketplace. If you don t know your annual household income, you can find out by collecting your W-2 form, recent pay stubs, and your income tax return form. You can visit to find out. How much can you spend on health insurance? Figure out how much you can afford to pay for health insurance. Think about your other monthly expenses such as food, transportation, and rent or mortgage payments. 18

20 Does your HIV provider participate in a health plan available to you? If your provider does not participate in the plan you select, you must pay additional costs to see that provider. This is called going out of network. Also, some health insurance plans consider HIV providers to be specialists. That means you may need to get a referral or other authorization from the insurer before seeing your provider. Some insurance plans may put limits on the number of visits you can make to a specialist. Think about these things when selecting your health insurance plan. If it is important to you to continue seeing your current health provider, try to choose a health insurance plan that your provider participates in. What are the limits for visits to your health provider s office? Will you have to share some of the costs? As a person living with HIV, it is important to see your health provider regularly to maintain regular care, get prescriptions for HIV and other medications, and keep a close watch on the disease and treatments. Make sure to ask if there are any limits on how many visits to your health provider are allowed each month or year. Also think about the cost sharing requirements such as co-pays and deductibles, on office visits. What are the limits and cost-sharing requirements for lab tests? Will you have to share some of the costs? Regular laboratory tests are needed to monitor your health status and to properly adjust treatment as appropriate. For this reason, it is important to ask if the insurance plan you are thinking about places limits on the number of lab tests for HIV-related tests, including CD4, viral load, genotyping, and phenotyping. Also become familiar with cost sharing requirements, such as co-pays and deductibles, on lab tests. Are your medications on the plan s prescription drug formulary? Make a list of all your medications so you can check to see if your particular drug treatment regimen is covered by the plans being offered. You should also find out about cost-sharing requirements such as co-pays or deductibles associated with their medications. Also learn about rules for prior authorizations or generic drug substitutions. Do you have other medical conditions? Will the insurance plan cover them? Many people living with HIV have other medical conditions. Get advice from your health professional about any other things you may need to think about when choosing a health insurance plan. Can you still receive support from the Ryan White Program/AIDS Drug Assistance Program (ADAP)? Depending on a state s Medicaid expansion status, you may need to access ADAP and Ryan White services to complete coverage offered by Marketplace plans, if you qualify. You can find a local Ryan White Program using the Health Resources and Service s Administration s locator tool: Introduction Landscape Overview Talking to Clients Resources 19

21 Guiding Your Clients to Under This guide is also provided in a tear-off pad at the back of this booklet, for distribution to your clients. Do you have Medicaid or Medicare? YES Continue care through Medicaid or Medicare Are you a U.S. citizen or legal resident? Start here YES NO NO Does your employer (or spouse s employer) offer affordable health insurance (costs <9.5% of household income)? NO Is your state expanding Medicaid? Receive care through Ryan White Program YES Continue care through (spouse s) employer insurance Household Size TABLE 2 Percent of federal poverty level (FPL) 100% 138% 250% 400% 1 $11,490 $15,856 $28,725 $45,960 2 $15,510 $21,404 $38,775 $62,040 3 $19,530 $26,951 $48,825 $78,120 4 $23,550 $32,499 $58,875 $94,200 5 $27,570 $38,047 $68,925 $110,280 6 $31,590 $43,594 $78,975 $126,360 7 $35,610 $49,142 $89,025 $142,440 8 $39,630 $54,689 $99,075 $158,520 For each additional person, add: $4,020 $5,548 $10,050 $16,080 20

22 standing Coverage Options NO YES Is your income <100% of FPL? (see Table 2) Is your income <138% of FPL? (see Table 2) YES Receive care through Medicaid NO NO YES Receive care through the Marketplace Receive care through Ryan White Program Incomes >400% of FPL can use Marketplace, but won t get cost breaks (see Table 2) Incomes % of FPL (or % for Medicaid expansion states) can use Marketplace and receive cost breaks (see Table 2) Introduction Landscape Overview Talking to Clients Resources 21

23 Steps to Enroll These steps are also provided in a tear-off pad at the back of this booklet, for distribution to your clients. Prepare: Discuss your health needs with your family and healthcare provider. Learn about the health insurance options in your state. Review your annual income, and determine what you can afford to spend on health insurance, before choosing a health insurance plan for you and your family. Act: Open Enrollment Runs From October 1, 2013 to March 31, 2014 Find the common application for the federal Marketplace at Review your annual income and household size to determine if you are eligible for tax credits, subsidies or other financial assistance. Evaluate your health needs, finances, and the benefits offered by each plan. Select your health insurance plan, taking into account out-of-pocket expenses including deductibles, co-insurance and co-payments. If You Enroll: Coverage Begins By Dec. 15, 2013 January 1, 2014 Dec , 2013 February 1, 2014 Jan. 1 15, 2014 February 1, 2014 Jan , 2014 March 1, 2014 Feb. 1 15, 2014 March 1, 2014 Feb , 2014 April 1, 2014 March 1 15, 2014 April 1, 2014 March 16 31, 2014 May 1, 2014 When Coverage Begins Remember: if you miss open enrollment, you can still purchase health insurance outside of the Marketplace, but tax credits will not apply. Key Information to Share With Your Clients December 15, 2013 is the deadline to enroll for coverage beginning January 1, Marketplace Open Enrollment runs from October 1, 2013 March 31, Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain Qualifying Life Events, which include, but are not limited to, moving to a new state, changes in income, and changes in family size (for example, a marriage, divorce, birth, or pregnancy). If your client plans to enroll in a plan in the Marketplace, do they know how to do so? (See Helping Your Clients Enroll in Coverage on page 23). 22

24 Qualifying for Tax Credits and Lower Payments If your client is eligible for cost savings such as tax credits or subsidies, do they know this? Enrollment in Medicaid Your clients can determine if they are eligible for Medicaid when applying for health coverage at the Marketplace s Application for Health Coverage. Medicaid coverage can begin at any time. There is no enrollment period. In states that take up the Medicaid expansion, all individuals with income up to 138% of the Federal Poverty Level are eligible for the program. In states that have not taken up the expansion, Medicaid has varied income qualifications. Informing Clients About Their Health Professionals Networks It is important to inform your clients about which health networks their healthcare team is included in. Otherwise, clients purchasing new insurance plans in the Marketplaces may select a plan for which their team is not in-network. Similarly, for your clients with new coverage under Medicaid, you should let them know whether you will still be their provider under Medicaid after Helping Your Clients Enroll in Coverage The U.S. Department of Health and Human Services (HHS) offers a single common application to determine eligibility for programs and assistance under healthcare reform. The process includes: Application for health coverage, which offers information about eligibility about buying health insurance through the Marketplace. The short form (Application for Health Coverage and Help Paying Costs), designed for individuals who know they are eligible to buy insurance through the Marketplace. The long form (Application for Health Coverage and Help Paying Costs), designed for families who know that they are eligible to buy health insurance through the Marketplace. Many systems have been set up to assist in client enrollment nationwide. Patient Navigators and Certified Enrollment Counselors are available in every state to help clients enroll in either health insurance plans offered in the Marketplaces or in Medicaid in their state. Where to Enroll Individuals may enroll for coverage online, by phone, and through in-person enrollment. They may apply either through the Marketplaces (in their state s Marketplace or the federal Marketplace if their state chose not to create its own Marketplace) or through their state Medicaid program. Many Community Health Centers also provide in-person enrollment assistance. The application will help identify eligibility for either Medicaid or for Qualified Health Plan coverage, and premium tax credits. 23 Introduction Landscape Overview Talking to Clients Resources

25 Section 3: Resources General Reference Sites American Academy of HIV Medicine The Academy supports HIV care providers by offering continuing medical education and professional credentialing. They also publish practice management materials and advocate at the state and federal levels on issues that impact clinical care. HIV Medicine Association Representing HIV healthcare providers, researchers and patients, HIVMA is an organization of medical professionals that advocates for policies that instate quality and comprehensive HIV care. HIVHealthReform.org Through blogs, newsletters and regular webinars, HIVHealthReform.org spreads awareness about the Affordable Care Act s improved healthcare access for people with HIV. Kaiser Family Foundation Kaiser is a nonprofit, private operating foundation concentrating on healthcare issues in the United States, as well as the U.S. role in global health policy. Among their topics of focus is the expanding coverage options the Affordable Care Act offers for people living with HIV. Healthcare Marketplaces This is the official U.S. government site for the healthcare Marketplaces. (Spanish) AIDS.gov This government-sponsored site provides federal and domestic HIV and AIDS resources to the general public, federal staff/agencies, state staff, federal grantees, medical and research institutions, and other HIV and AIDS-related organizations. 24

26 For People Living With HIV and Their Caregivers The Affordable Care Act and You Seven steps consumers can take to prepare for 2014 s healthcare reform, courtesy of the Florida AIDS Drug Assistance Program (ADAP). Lifelong AIDS Alliance Health Reform Education Materials Get the basics on healthcare reform, changes relevant for those with chronic conditions and Federal Poverty Level chart. Marketplace Information Brochure for People With HIV (PDF) Brought to you by Duke University School of Law AIDS Legal Project, this brochure outlines: the Marketplace, how insurance works, and how ADAP and Ryan White play a role. AARP Health Law Answers This interactive tool from AARP allows the individual to tailor answers that best fit their personal situation. State Decisions for Creating Health Insurance Exchanges At an easy glance, see which state is doing a federal exchange, a partnership exchange, or a statebased exchange. Beyond the Pledges: Where the States Stand on Medicaid At an easy glance, see which states have decided to expand Medicaid. Introduction Landscape Overview Talking to Clients Resources 25

27 For Health Professionals HIV-specific Q & A for Clients on Health Reform Two-page Q & A created by HIV advocates in San Francisco for educating clients. Readiness for Health Insurance Participation by Ryan White Providers: The Time Is Now! Reform readiness presentation from Julia Hidalgo of Positive Outcomes, Inc. NASTAD Health Reform Central The National Alliance of State and Territorial AIDS Directors healthcare reform page, including issue briefs on topics such as essential health benefits and monthly healthcare reform updates. AAHIVM: Health Reform Resource Center for HIV Providers This site is targeted at HIV providers to offer a resource on the health system changes occurring in each state. HIVMA Implementation Resources for Medical Providers The HIV Medicine Association s center for healthcare reform implementation, featuring a number of fact sheets designed for health professionals. HIVMA Preparing for Enrollment: What HIV Providers Need to Know (PDF) This document compiles enrollment information and resources for HIV medical providers. Ryan White TARGET Center: Healthcare Reform Implementation Tools For Ryan White agencies that need technical help in navigating healthcare reform s changing coverage options for clients, payment mechanisms, and care delivery. 26

28 For Community-based Organizations HIVMA Healthcare Reform and Essential Community Providers (ECPs) Instructions for Ryan White providers and community-based organizations to becoming ECPs, allowing them to contract with marketplace insurance plans. HIVHealthReform.org Webinar: Pathways to Collaboration Nonmedical providers such as community-based organizations and new healthcare reform health home programs can work together to be ready for healthcare reform. CMS.gov/Outreach and Education Customizable materials that groups such as faith- and community-based organizations can use to educate communities about health insurance Marketplaces. Introduction Landscape Overview Talking to Clients Resources 27

29 Timeline 32 Enrollment begins in health insurance Marketplaces Open enrollment for 2014 coverage ends October 1 March 31 October January 1 Medicaid expansion takes effect (not all states participating) Individual mandate begins Open enrollment for 2015 coverage begins Health insurance Marketplaces begin operation Plans in Marketplaces must offer essential health benefits Insurers in Marketplaces are prohibited from setting premiums on the basis of health status Insurers are prohibited from denying policies to individuals with preexisting conditions Subsidies available to low-income individuals purchasing coverage in Marketplaces; tax credits available to some low-income individuals and small businesses Annual dollar limits on coverage of essential health benefits removed Out-of-pocket costs for essential health benefits limited to maximum threshold of high-deductible health plans ($6,250 for an individual in 2013) 28

30 January 1 January 1 January 1 Businesses with 50 full-time employees must play or pay If we purchase a plan through the Marketplace, when will our coverage begin? Small businesses ( 100 covered workers) allowed to shop for employee benefits in health insurance Marketplaces Large businesses ( 101 covered workers) allowed to shop for employee benefits in health insurance Marketplaces Introduction Landscape Overview Talking to Clients Resources 29

31 Glossary Affordable Care Act (ACA) The Patient Protection and Affordable Care Act, most frequently called just the Affordable Care Act or simply ACA, is a comprehensive healthcare reform bill. The goal of the ACA is to expand healthcare access and coverage, increase consumer protections, control healthcare costs, and improve quality and system performance. AIDS Drug Assistance Program (ADAP) ADAPs provide HIV-related prescription medications to low-income people with HIV who have limited or no drug coverage. ADAPs make up Part B of Ryan White Programs (see Ryan White Programs). Annual dollar limits Maximum benefits payable, in terms of dollars, by an insurer for a beneficiary during a plan year. Healthcare reform eliminates annual limits for essential health benefits in Co-payment An out-of-pocket expense that your plan specifies for health-related services such as a doctor visit, emergency room visit, or prescription medication. Deductible Amount paid in out-of-pocket expenses before health insurance plan pays a claim. Essential Health Benefits (EHBs) EHBs cover a wide range of basic health services, from preventive care, office visits, lab tests and prescriptions to emergency services, hospitalization, rehabilitation care and mental health and substance abuse treatment. Health insurance plans sold through the Marketplace must ensure that these essential EHBs are provided with no coverage limit. The Exchange See The Marketplace. Explanation of benefits (EOB) An EOB form is a statement sent by your health insurance company that lists the medical services and/or treatments for which you or your providers have sent claims for coverage. These statements are not bills. 30

32 Federal Poverty Level (FPL) The FPL is a measure of household income issued annually by the Department of Health and Human Services to determine your eligibility for certain programs and benefits. Federally Qualified Health Center (FQHC) An FQHC is a reimbursement designation that allows participation in federal programs. Ryan White clinics that achieve FQHC status can contract and interact with Medicaid programs and health plans. Individual mandate The individual mandate is a federal requirement that lets people without job-based benefits or public coverage (such as Medicaid or Medicare) purchase insurance. If you are not enrolled in a health insurance plan, you may be required to pay a tax penalty. This penalty will be either one percent of your taxable income or $95 in 2014 whichever amount is greater. The percentage and dollar amount of the penalty will increase every year you are without health insurance. There are, however, some exceptions to the individual mandate, such as if you have a very low income or you have certain religious beliefs. Lifetime limits Maximum benefits payable, in terms of dollars, by an insurer for a beneficiary over his or her lifetime. Healthcare reform eliminated lifetime limits for essential health benefits in The Marketplace The health insurance Marketplace is an online portal where a variety of insurance providers will offer their products for you to compare health plans, ask questions, find out if you are eligible for tax credits, and select a coverage plan that works best for you. It is designed to make buying health coverage easier and more affordable. Medicaid Medicaid is a joint federal-state health insurance program for low-income and disabled individuals. In 2014, people with incomes less than or equal to 138 percent of the FPL (see Federal Poverty Level) will be eligible for Medicaid in states expanding their programs. Introduction Landscape Overview Talking to Clients Resources 31

33 Glossary (continued) Metal Levels While all Marketplace plans will cover essential benefits, there are four levels of individual coverage available. These levels are called bronze, silver, gold and platinum. Bronze plans will feature the lowest monthly premiums, but cover only 60 percent of average costs. Platinum plans will cover 90 percent of expected costs. Out-of-Pocket Expenses Out-of-pocket expenses are what you pay for health-related services in addition to your monthly premium. Premium The amount you pay monthly for a health insurance plan. Ryan White HIV Program Provide HIV-related services to more than half a million people with HIV who do not have sufficient healthcare coverage or financial resources to address their disease. Ryan White Programs can fill gaps in care not covered by insurers, but the programs do not satisfy the individual mandate. Safety Net Programs Safety net programs are noncontributory programs designed to help low-income individuals and families maintain a basic level security and prevent them from falling into poverty. These programs can be from both the public sector, at the state and federal levels, and the private sector. A common HIV safety net program is the AIDS Drug Assistance Program (ADAP), which is a part of Ryan White. Tax Credits For low-income people between 100% and 400% of the Federal Poverty Level (FPL) and unable to take advantage of Medicaid expansion, tax credits may help individuals and families purchase coverage in the Marketplace. These tax credits will lower the cost of their monthly health plan premiums. The premium tax credit will help make insurance more affordable because they will be paid in advance to your insurance company to help cover the premium cost. With healthcare reform, you will be able to buy insurance through either the Marketplace or from a private insurance company. It is important to note, however, that the tax credits to help with payments will be available only if you purchase insurance through the Marketplace. 32

34 Bibliography 2013 Poverty Guidelines. Office of the Assistant Secretary for Planning and Evaluation. U.S. Department of Health and Human Services, n.d. Web. 06 Sept < AAHIVM Resource Center for HIV Providers, American Academy of HIV Medicine. Web. 11 Sept < About the Ryan White HIV Program. Health Resources and Services Administration. U.S. Department of Health and Human Services, n.d. Web. 06 Sept < Affordable Care Act and HRSA Programs. HRSA. U.S. Department of Health and Human Services, n.d. Web. 06 Sept < Affordable Insurance Exchanges Guidance. Centers for Medicare and Medicaid Services. U.S. Department of Health and Human Services, 03 Jan Web. 06 Sept < Downloads/partnership-guidance pdf>. Crowley, Jeffrey S., and Jen Kates. The Affordable Care Act, the Supreme Court, and HIV: What Are the Implications? Kaiser Family Foundation. The Henry J. Kaiser Family Foundation, 24 Sept Web. 06 Sept < Do I Qualify for Medicaid? HealthCare.Gov. U.S. Centers for Medicare and Medicaid Services. Web. 06 Sept < Essential Health Benefits. HealthCare.Gov. U.S. Centers for Medicare and Medicaid Services. Web. 06 Sept < Federal Healthcare Reform: Patient Protection and Affordable Care Act Individual Mandate and Subsidy. BlueCross BlueShield of Rhode Island. BlueCross BlueShield of Rhode Island, 11 Apr Web. 06 Sept < Frequently Asked Questions. CMS.Gov. Centers for Medicare and Medicaid Services, n.d. Web. 06 Sept < Health Care Reform and YOU, July 2013, AIDS Foundation of Chicago. Web. 09 Sept < HIV Care in a Changing Healthcare Landscape: Effect of Healthcare Reform on Ryan White Programs and ADAP. Titusville: Janssen Therapeutics, Division of Janssen Products, LP, July September PDF. HIV Care in a Changing Healthcare Landscape: The Intersection of Healthcare Reform and HIV Care. Titusville: Janssen Therapeutics, Division of Janssen Products, LP, July PDF. HIV in the United States: The Stages of Care, July 2012, CDC, Centers for Disease Control and Prevention, 12 September < How Can I Get Ready to Enroll in the Marketplace? HealthCare.Gov. U.S. Centers for Medicare and Medicaid Services. Web. 06 Sept < Introduction Landscape Overview Talking to Clients Resources 33

35 Bibliography (continued) Key Provisions of the Affordable Care Act for the Ryan White HIV Program. HRSA. U.S. Department of Health and Human Services, 05 Mar Web. 06 Sept < Mann, Cindy, and Mary Wakefield. Coordination between Medicaid and Ryan White HIV Programs. U.S. Department of Health and Human Services and Centers for Medicare and Medicaid Services, 01 May PDF. 06 Sept < Ryan White & Health Care Reform: Future Paths for Integration, Expansion, and Innovation. Boston: Harvard Law School Health Law and Policy Clinic & Treatment Access Expansion Project, PPT. < wp-content/uploads/2011/10/presentation-on-ryan-white-and-hcr-integration-from-taep.pdf>. Status of State Action on the Medicaid Expansion Decision, as of September 3, Kaiser Family Foundation. Henry J. Kaiser Family Foundation, 03 Sept Web. 06 Sept < state-activity-around-expanding-medicaid-under-the-affordable-care-act/>. Updating the Ryan White HIV Program For A New Era: Key Issues and Questions for the Future. Kaiser Family Foundation. Henry J. Kaiser Family Foundation, 01 Apr Web. 06 Sept < updating-the-ryan-white-hivaids-program-for-a-new-era-key-issues-and-questions-for-the-future/>. What If My State Is Not Expanding Medicaid? HealthCare.gov. U.S. Centers for Medicare and Medicaid Services. Web. 06 Sept < What Is the Difference Between Medicare and Medicaid? HHS FAQ. U.S. Department of Health and Human Services. Web. 06 Sept < 34