Early Intervention Program (EIP)

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2 Early Intervention Program (EIP) Manages Washington State s AIDS Drug Assistance Program (ADAP) Housed at the Department of Health EHIP is EIP s contracted Insurance Benefits Manager Ramsell Corporation is EIP s contracted Pharmacy Benefits Manager 2

3 EIP Eligibility Requirements Have proof of HIV positive status Live in Washington State Have a gross monthly income at or below 400% of the Federal Poverty Level (FPL) If at or below 138% FPL and if eligible for Medicaid, clients are required to enroll into Medicaid through the WAHealthPlanFinder Clients eligible for Medicaid are not eligible for EIP or EHIP Must renew eligibility every six months after being approved for EIP 3

4 EIP Funding EIP receives federal ADAP earmark funding from Part B of the Ryan White Care Act ADAP-AIDS Drug Assistance Programs Programs in all 50 states that provide approved HIV treatment drugs to Low Income people with HIV States administer the federal funds differently WA State was one of the first to use the funds to provide premium assistance Program began in 1987 to pay for AZT. Expanded in 1990 with the Ryan White Care Act 4

5 EIP Provides it own Medical Benefits Management Ramsell Corp Pharmacy Benefits Manager EHIP Insurance Benefits Manager 5

6 Ramsell Corporation Pharmacy Benefits Manager for EIP Adjudicates all medication claims, whether it be full pay or co-pay A Ramsell card is issued when a client becomes eligible for EIP Manages contracts for over 1000 pharmacies across the state 6

7 Early Intervention Program (EIP) EIP in-house medical benefits management provides: Covers HIV related care (Dr. appointments and lab work) with contracted providers Covers Dental and Mental Health with contracted providers Pays towards deductible, but only for EIP covered services with a contracted provider Covers all HIV medications If Uninsured, EIP covers drugs based on their formulary If Insured, EIP covers all prescription drug co-pays 7

8 Evergreen Health Insurance Program (EHIP) Contracted with DOH Early Intervention Program (EIP) as their Insurance Benefits Manager EHIP is a program of Lifelong, a non-profit that has been serving the HIV community for over 30 years Pays health insurance premiums for people living with HIV that are EIP eligible Insurance experts and a resource for EIP, HIV Case Managers, and Clients Clients must be enrolled in EIP to be eligible for EHIP EIP determines eligibility for both programs 8

9 History Originally, WA State s ADAP program was managed by DSHS EHIP was set up by Lifelong (formally NW AIDS Foundation) in 1991 to manage the premium assistance program Management of ADAP was moved to DOH in 1993 First year of the ACA brought dramatic changes to EHIP Over 1000 clients became eligible for Expanded Medicaid 1250 clients moved from WSHIP to an ACA plan or Apple Health Premium Assistance fell from $23,000,000 to under $10,000,000 9

10 Comprehensive Coverage WA State was one of the first ADAPs to provide premium assistance rather than just paying for HIV Medications Philosophy is that comprehensive medical coverage removes barriers to adherence to medications End AIDS Washington Goals by 2020 Reduce the rate of new HIV diagnoses by 50% Increase suppressed viral loads by 80% Reduce morality rates for PLWH by 25% Reduce HIV-related health disparities Improve quality of life for PLWH 10

11 EHIP Staff Program Manager Three Insurance Advocates Insurance Coordinator Payment Supervisor Quality Analyst 11

12 EHIP Can Pay For: Approved Silver & Gold Exchange Plans on the WAHealthplanfinder.org Medicare Part D (PDP Plans) & Medicare Part C (MAPD plans) Employee Sponsored Insurance Plans (ESI or Group Plans) HWD s (Health Care for Workers with Disabilities) WSHIP plans for clients currently enrolled Individual Plans outside the Exchange 12

13 EHIP Cannot Pay For: Stand-alone dental, vision, life, etc. Medicare Part A Medicare Part B Medicare Supplement Insurance (Medigap) Medicare Advantage plans without Rx coverage Catastrophic plans* Bronze level plans* HSA s, FSA s & HRA s* QHP s & Individual plans not on EIP/EHIP s approved list* COBRA s* *Exceptions can be made if already enrolled and outside Open Enrollment period; required to change during the next Open Enrollment to an approved plan 13

14 How to Enroll into EHIP If client is new to EIP and EHIP, submit EIP application and indicate yes to premium assistance If client is existing EIP client, submit New Enrollment/New Payable form to EHIP Submit bills & all required additional paperwork to EHIP 14

15 Documentation Required Medicare Part C & D Bill (submit as soon as received) HWD Bill (submit as soon as received) Retirement Plan Bill (submit as soon as received) Summary of Benefits (SOB) Drug Formulary COBRA (existing plan only) Bill (submit as soon as received) Summary of Benefits (SOB) Drug Formulary Qualified Health Plan (QHP) Plan Selection Confirmation page or bill Individual Plans Bill (submit as soon as received) Employer Sponsored Insurance (ESI) Employer Form Summary of Benefits Drug Formulary 15

16 2018 Premium Assistance Numbers Total clients Served 2,379 Total months of coverage paid for 22,556 Total amount of premiums paid $10,542, % of clients enrolled in EIP receive EHIP Premium Assistance Large number of clients enrolled in Medicare have a $0 premium due to subsidy programs Clients enrolled in ESI s often do not need premium assistance or employer does not accept EHIP payments Between 4% and 9% of EIP enrollees remain uninsured yearly 16

17 2019 Preliminary Enrollment Numbers Qualified Health Plans-852 Individual Plans-186 (Will increase as we receive January premium confirmations) Medicare Part D Plans-284 Medicare Part C Plans-461 HWD Plans-22 ESI/Group/Retirement Plans-114 WSHIP-219 Total as of 1/7/2019:

18 Questions? 18