The Affordable Care Act: Preparing Part B and ADAPs for Implementation. Amy Killelea, JD NASTAD Ryan White 2012 Grantee Meeting November 29, 2012

Transcription

1 The Affordable Care Act: Preparing Part B and ADAPs for Implementation Amy Killelea, JD NASTAD Ryan White 2012 Grantee Meeting November 29, 2012

2 Presentation Overview Part 1: Timeline and Decision Points Part 2: Federal and State Implementation Update Public Insurance Reforms Private Insurance Reforms Health Infrastructure Reforms Part 3: Health Reform Planning and Next Steps Part 4: Questions Resources

3 Part 1: Timeline and Decision Points

4 Timeline and Decision Points

5 Timeline and Decision Points Source: Treatment Access Expansion Project, May 2012

6 Part 2: Federal and State Implementation Update

7 The ACA and Ryan White Programs: Identifying the Questions Key Questions for RW Part B and ADAPs: How many RW clients in my state will be eligible for ACA insurance expansion? How will ACA benefits requirements interact with RW services? Is my state ADAP able to ramp up its insurance assistance program to accommodate newly insured clients? Does my state have adequate consumer outreach and patient navigation capacity?

8 The Medicaid Expansion and What It Means in My State The Supreme Court Decision and What It Means for Medicaid 1) ACA UPHELD in its entirety 2) Medicaid expansion upheld, but enforcement limited The penalty for state non compliance with the expansion is limited to loss of Medicaid expansion funds; federal government cannot pull funds for the entire Medicaid program if states do not comply with the expansion.

9 Medicaid Reforms: The Medicaid Expansion and What It Means in My State Eligibility expansion to most people w/income up to 138% FPL Full federal funding for No date by which states must notify CMS if they intend to expand; states can opt in or out of expansion after Essential Health Benefits for newly-eligible Medicaid beneficiaries Streamlined application and enrollment processes Enhanced reimbursement for primary care providers in Significant reductions in disproportionate share hospital (DSH) payments

10 The Medicaid Expansion and What It Means in My State What happens in a state that does not comply with expansion?

11 The Medicaid Expansion and What It Means in My State Medicaid Coverage of Low Income Adults, January 2012

12 The Medicaid Expansion and What It Means in My State Medicaid Expansion: Where Do States Stand? Source: Center on Budget and Policy Priorities (September 2012)

13 The Medicaid Expansion and What It Means in My State Implementation Update: Will the Medicaid Benchmark Plan Cover Necessary Care and Treatment? Medicaid benchmark plans have been used by states to offer slimmer benefits packages: Wisconsin BadgerCare Core Plan: Restricted formulary Co-payments Service limits Benchmark plans could be used to offer targeted benefits to specific populations

14 The Medicaid Expansion and What It Means in My State Implementation Update: Enhanced Reimbursement for Primary Care Providers In , physicians with specialty designation of family medicine, general internal medicine, or pediatric medicine or subspecialty are eligible to receive enhanced Medicaid reimbursement (pegged to Medicare rates) for primary care services States must put in place systems to identify eligible providers

15 The Medicaid Expansion and What It Means in My State Why Medicaid Reimbursement Matters Source: Sandra L. Decker, In 2011 Nearly One-Third Of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help, Health Affairs (2012)

16 The Medicaid Expansion and What It Means in My State Federal deficit reduction Ongoing state opposition Fast timeline Will states fully implement the ACA s Medicaid expansion?

17 Private Insurance Reforms and What They Mean in My State Implementation Update: Exchange Establishment Options for exchange implementation: State-based exchange (14 states and DC so far) Federally-facilitated exchange Partnership/hybrid model ALL exchanges must have: Outreach/patient navigator programs Plan certification criteria (including network adequacy standards) Interface w/medicaid

18 Private Insurance Reforms and What They Mean in My State State Progress on Exchanges

19 Private Insurance Reforms and What They Mean in My State Implementation Update: Essential Health Benefits (EHB) HHS adopted benchmark approach, meaning the specifics of the EHB will be determined by each state States choose from ten benchmark options (based on plans in the existing insurance market) by Dec Benchmark must include the ten categories of EHB benefits AND mental health parity Ongoing concerns: Still very little regulation on plan content requirements Non-discrimination requirements are weak Service limits & utilization management may continue Some positive language on prescription drug coverage (movement away from one drug per class standard)

20 Private Insurance Reforms and What They Mean in My State Implementation Update: Affordability of Insurance Advance Premium Tax Credits for people with income between 100 and 400% FPL Tax credit = difference between benchmark premium and taxpayer s expected contribution Expected contribution based on annual income and increases as income increases (2% of income for people at 100% FPL to 9.5% people at 400% of FPL) Based on end-of-year tax filings and paid in advance directly to plans (member responsible for overpayment) Cost-sharing reductions for people with income between 100 and 250% FPL Increases actuarial value to reduce member contribution Out-of-pocket spending caps Based on Modified Adjusted Gross Income (MAGI)

21 Private Insurance Reforms and What They Mean in My State Basic Health Plan States have the option of creating a public option for people with income between 138 and 200% FPL Largely funded with federal dollars EHB requirements apply Minimizes churning between Medicaid and exchange Implementation Update No federal rules yet, but states are moving forward designing benefits and coordinating with Medicaid and exchanges

22 Private Insurance Reforms and What They Mean in My State Pre-existing Condition Insurance Plans (PCIPs) High risk pools to allow people with pre-existing conditions to access comprehensive insurance coverage 27 state run; 23 federally run Temporary program Implementation Update Federal challenges/hurdles to facilitating access to PCIP coverage for ADAP clients Federal regulations on PCIP transition forthcoming

23 Health Reform Investments: Where Will People Get Care? Health Infrastructure Reforms $11 billion investment to expand community health center capacity Investment in health workforce (e.g., National Health Service Corps and primary care workforce) Investment in coordinated care models to improve quality of care and reduce costs (e.g., Medicaid Health Home Program) Investment in Prevention and Public Health Fund to fund community prevention initiatives

24 Consumer Outreach Opportunities HIV/AIDS Programs and Providers Insurance Assisters Patient Navigator Program Medicaid Outreach Consumer outreach and enrollment

25 Health Reform and Immigrants Undocumented individuals completely left out of health care reform No access to Medicaid or the Exchanges Ryan White will continue to provide care Exploring HIV care collaborations with Community Health Clinics is important Legal Immigrants in the U.S less than 5 years (with some exceptions) Not eligible for Medicaid Can purchase/receive subsidies in the Exchange Can receive care in a Basic Health Plan

26 Part 3: Health Reform Planning and Next Steps

27 Health Reform Next Steps 1) Getting to the table Challenges in engaging in state process: Finding the decision makers VERY fast timeline HIV is small piece of larger planning issues Successful strategies for involvement: State HIV/AIDS Ryan White all parts meetings as venue to engage Medicaid and others on health reform (KY, MN, TX) Engagement with other stakeholders

28 Identifying number of clients who will be affected Eligible for Medicaid Eligible for subsidized private insurance Those left out of reform (undocumented immigrants and legal immigrants within 5 year ban) Health Reform Next Steps 2) Once at the table ensuring HIV planning for Medicaid expansion and Exchange development ADAP Clients Served, by Insurance Status, June 2011 Payer Medicaid Medicare Dually Eligible (Medicaid & Medicare) Private Insurance PCIPs Uninsured 2% 6% 10% 15% 21% 60% 0% 10% 20% 30% 40% 50% 60% 70% Percent of Clients Two-thirds (68%) of ADAP clients had income levels at or below 200% FPL

29 Health Reform Next Steps 3) Identifying and planning to fill gaps in covered services and affordability E.g., insurance assistance E.g., support services E.g., dental and vision services Source: Commonwealth Fund,2012

30 Health Reform Next Steps 4) Prepare Ryan White systems to serve post reform ADAPs must be able to wrap around insurance coverage Massachusetts ADAP Expenditures by Category Fiscal Year Full Pay Co-Pay Premiums FY05 $ 9,756, $ 1,839, $ 6,112, FY10 $ 4,635, $ 2,930, $ 9,320, Waiver from 75/25 rule RW Integration and wrap around Medicaid/ Exchange plan services

31 Health Reform Next Steps 5) Preparing and planning for health reform at the local level Infrastructure of ASOs to handle insured client base? Connections to broader care systems to ensure uninterrupted access to care? Community health centers Safety net providers Medicaid Engagement in education and training in new systems to provide assistance to clients?

32 Health Care Reform and ADAPs

33 Part 4: Questions

34 Resources

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