Ryan White Moving Forward and ACA Implementation

Transcription

1 Ryan White Moving Forward and ACA Implementation U.S. Conference on AIDS, San Diego, CA October 2, 2014 HIV/AIDS Bureau Health Resources and Services Administration U.S. Department of Health and Human Services

2 Presenters Laura Cheever, MD, ScM Associate Administrator HIV/AIDS Bureau Health Resources and Services Administration Antigone Dempsey, MEd Director, Division of Policy and Data HIV/AIDS Bureau Health Resources and Services Administration

3 Agenda for Seminar Ryan White Moving Forward and ACA Implementation Agenda 2:30 3:30 HIV/AIDS Bureau Presentation on updated PCNs, vigorously pursue and open enrollment (45 min) Questions and Answers (15 min) 3:30 4:20 Grantee Presentations - Part B Grantee: Kentucky - Part A Grantee: San Franciciso 4:20 4:40 Break 4:40 5:30 ACE Project - Interactive Activity (40 min) - Tools Available Through ACE (10 min) Laura and Antigone Karen Sams Celinda Cantu Mira Levinson Stuart Landers

4 Overview HIV/AIDS Bureau Ryan White HIV/AIDS Program (RWHAP) Moving Forward Priorities Moving forward with the Affordable Care Act (ACA) and RWHAP o Refresher and Updates on HIV/AIDS Bureau (HAB) Policies o Strategies for Vigorously Pursue o Outreach and Enrollment o Resources Question and Answer Period

5 HIV/AIDS Bureau s Framework

6 HIV/AIDS Bureau FY 2015 Priorities Implement the National HIV/AIDS Strategy (NHAS) Focus on areas of greatest health disparities and care continuum Integrate the Ryan White HIV/AIDS Program and the Affordable Care Act Advance data utilization to demonstrate outcomes Enhance partnerships to improve outcomes

7 HIV/AIDS Bureau FY 2015 Priorities (cont.) The Affordable Care Act and RWHAP Integrating the RWHAP into ACA oproviding additional guidance as needed oproviding technical assistance highlighting best practices oevaluating RWHAP client health care needs in shifting health care landscape and filling gaps Considering new ways of distributing RWHAP funding in context of new resources in the health care environment

8 WHO DOES THE RYAN WHITE HIV/AIDS PROGRAM SERVE?

9 Ryan White Service Data 2012 During calendar year 2012, an estimated 536,219 individuals received at least one RWHAP-funded service Based on CDC (2011) estimates, RWHAP served 60% of estimated persons diagnosed HIV infection (n=888,921)

10 Gender of Adult & Adolescent RWHAP Clients, Calendar Years % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 68% 69% 70% 31% 30% 29% 1% Male Female Transgender RSR 2010 RSR 2011 RSR 2012 *For all three years, less than 1% of clients served were transgender. Gender was unknown or missing for 413 clients in 2010, 233 clients in 2011, and 173 clients in 2012.

11 Ryan White Services Report, Race/Ethnicity of Clients Served 50% 40% 30% 20% 10% 0% 2010 (N=543,075) 2011 (N=540,192) 2012 (N=540,219) Race/ethnicity is unknown or missing for 13,100 clients in 2010, 13,807 clients in 2011, and 9,973 clients in Race and ethnicity is required for all clients regardless of services received.

12 Ryan White Services Report, , Age of Clients Served* 40% 35% 30% 25% 20% 15% 2010 (N=555,955) 2011 (N=553,986) 2012 (N=536,200) 10% 5% 0% < Birth year is missing for 220 clients in 2010, 13 clients in 2011, and 19 clients in Birth year is required for all clients regardless of services received.

13 Ryan White Services Report, , Client Payer Source 2012 N = 499, % 13.0% 8.9% 26.0% 8.3% 27.6% 14.4% N = 466, % % 9.2% 27.0% 6.8% 27.8% 13.2% N = 429, % % 9.3% 27.4% 7.8% 26.1% 12.9% 0% 20% 40% 60% 80% 100% Private Medicare Medicaid Other Public No Insurance Other Multiple Ins. Payer source is unknown or missing for 78,463 clients in 2010, 45,918 clients in 2011 and 36,502 clients in Payer source is required for clients who received any core medical service or non-medical case management services.

14 Annual household income is unknown or missing for 76,134 clients in 2010, 49,743 clients in 2011, and 53,168 clients in Ryan White Services Report, Annual Household Income for Clients Served % N = 483, % 6.7% 4.7% % N = 376, % 6.7% 4.9% % N = 416, % 6.5% 5.2% 0% 20% 40% 60% 80% 100% < = 100% FPL 101% - 200% FPL 201% - 300% FPL > 300% FPL

15 Top 10 Medical Services Used, By Year Service Outpatient Ambulatory Medical Care* 56.7% 57.0% 60.6% 2. Medical Case Management* 52.9% 54.2% 54.3% 3. Case Management 26.1% 27.0% 26.1% 4. Oral Health* 15.8% 16.1% 16.9% 5. Transportation 14.2% 14.0% 14.0% 6. Mental Health* 13.6% 13.8% 14.0% 7. Health Education Risk Reduction 12.8% 12.0% 12.0% 8. Food Bank 12.0% 10.7% 10.5% 9. Psychosocial Support 11.4% 10.6% 9.6% 10. Treatment Adherence 9.4% 10.3% 12.2% *Core Medical Services

16 Ryan White Service Data ALONG THE CARE CONTINUUM

17 CDC Stages of Care 2009 National HIV Surveillance System & Medical Monitoring Project CDC. HIV in the United States: Stages of Care. July Hall HI, Frazier EL, Rhodes P, et al. JAMA Internal Medicine. Jun :1-7.

18 Ryan White Services Report, Retention in Care & Viral Suppression Retained in care: had at least 1 OAMC visit before September 1, 2012, of the measurement year and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200

19 2012 RSR Data Retention in Care and Viral Load Suppression by Race/Ethnicity 100% 80% 60% 81.7% 81.4% 84.4% 85.5% 84.8% 79.5% 79.9% 81.4% 82.6% 79.9% 76.5% 77.9% 74.5% 69.8% 40% 20% 0% White Black Asian Native Hawaiian American Indian Hispanic Multi-racial Retention in Care Viral Suppression

20 2012 RSR Data 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Retention in Care and Viral Load Suppression by Gender 82.1% 83.5% 75.9% 73.1% 80.4% 82.5% 68.9% Male Female Transgender All Retention in Care Viral Suppression 75.0% Retained in care: had at least one OAMC visit before September 1, 2012, and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200

21 2012 RSR Data Retention in Care and Viral Load Suppression by Age Retained in care: had at least one OAMC visit before September 1, 2012, and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200

22 2012 RSR Data 100% 80% 60% 40% 20% 0% Retention in Care and Viral Load Suppression by Risk Category 82.4% 81.9% 80.4% 81.8% 83.0% 83.4% 85.5% 77.5% 76.8% 74.7% 73.8% 80.5% 74.0% 80.4% 61.4% 73.6% Retention in Care Viral Suppression

23 MSM and IDU Retained in Care and Virally Suppressed Source: 2012 RSR data (preliminary) 100% 90% 80% 70% 60% 50% 82% 82.05% 79.6% 81.30% 74.4% 75.10% 76.39% 74.50% 67.8% 52.9% All RSR clients MSM 40% Black MSM 30% 20% Young (13-24) MSM IDU 10% 0% Retained in care Virally suppressed Retained in care: had at least one OAMC visit before September 1, 2012, and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200

24 2012 RSR Data Retention in Care and Viral Load Suppression by Insurance Status

25 Moving Forward with ACA Antigone Dempsey Director, Division of Policy and Data

26 HIV/AIDS Bureau Policy Clarification Notices REFRESHER

27 Health Coverage Options for PLWH AFTER the Affordable Care Act PLWH eligible for health coverage Employer- Based Insurance Medicaid Medicare Other Public Health Insurance Marketplace Other Private Cover comprehensive HIV medical and support services not covered, or partially covered, by public programs or private insurance Ryan White HIV/AIDS Program Cover comprehensive HIV medical and support services not covered, or partially covered, by public programs or private insurance PLWH who remain uninsured

28 Outline of Recent HAB Policies Policy Clarification Notices Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services by Ryan White HIV/AIDS Program Clarifications on Ryan White Program Client Eligibility Determinations and Recertifications Requirements Ryan White HIV/AIDS Program Client Eligibility Determinations: Considerations Post-Implementation of the Affordable Care Act Clarifications Regarding Clients Eligible for Private Health Insurance and Coverage of Services by Ryan White HIV/AIDS Program Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Private Health Insurance Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Medicaid Uniform Standard for Waiver of Core Medical Services Requirement for Grantees Under Parts, A, B, and C Clarifications Regarding the Ryan White HIV/AIDS Program and Reconciliation of Advance Premium Tax Credits Under the Affordable Care Act

29 Areas of Continued Focus Vigorously Pursue and Rigorously Document Dual Coverage Purchasing Insurance

30 VIGOROUSLY PURSUE & RIGOROUSLY DOCUMENT

31 Payer of Last Resort Requirements within the Context of ACA By statute, RWHAP funds may not be used for any item or service to the extent that payment has been made, or can reasonably be expected to be made by another payment source Grantees must vigorously pursue enrollment in other relevant funding sources RWHAP grantees must assess individual clients that are not eligible for public programs for eligibility for private insurance. The RWHAP will continue to pay for items or services received by individuals who remain uninsured or underinsured

32 Role of the RWHAP Post ACA Provide a safety net for people living with HIV that have little or no income Provide services for those that may not be eligible for other forms of assistance Provide coverage for needed services that may not be covered by other types of insurance Provide an entry way to medical care and assist in enrolling in other, more comprehensive coverage

33 Guiding Principles for Implementation of Vigorously Pursue ACA healthcare coverage is a good thing for PLWH, it means having access to a full spectrum of primary care medical services RWHAP is still needed to serve its mission of serving PLWH as a safety net PLWH still need support services, not typically covered by Medicaid or a Qualified Health Plan that support engagement and retention to care

34 Guiding Principles for Implementation of Vigorously Pursue (cont.) Enrolling in health insurance coverage may be a difficult transition for a small piece of our population (e.g., PLWH who are homeless, dealing with mental health or substance abuse issues, or distrustful of the medical system as a whole). RWHAP can act as a payer of last resort for these people, as long as grantees document attempts to enroll and continue to educate clients about ACA Organizations need to create policies, procedures and documentation practices when implementing vigorously pursue

35 Framework for Vigorously Pursue Establish Policies Establish Procedures Document Vigoursly Pursue allows for a process that ensures that PLWH continue to receive care and treatment services while being informed, educated and enrolled into eligible coverage systems. RWHAP is the payer of last resort throughout this process so that PLWH are not lost to care or lose access to medications.

36 Practices for Implementing Vigorously Pursue Establish Policies Establish Procedures Comprehensive organizational policies that Clearly detailed and clearly outline the goals delineated procedures for and process education, enrollment and tracking for all clients Document Tools specifically created to document enrollment and discussions with PLWH

37 Organizational Practices for Implementing Vigorously Pursue Grantee created a comprehensive approach to the entire landscape of health care for the jurisdiction: including policies, procedures, documentation and timelines for making the changes to their EMA Example: Grantee Strategy: Identify, Inform, Educate, and Enroll

38 Components of Policies for Vigorously Pursue A description of the Federal Marketplace A specific plan for coordination of patients into the ACA healthcare environment Specific procedures for the transition Education and enrollment goals, including written RWHAP provider roles, ASO roles, EMA Planning Council roles, RWHAP client roles, and Part B+ADAP roles

39 Components of Policies for Vigorously Pursue (cont.) Need for a timeline of important ACArelated dates which includes target dates for RWHAP ACA screening and enrollment Create ACA quality improvement processes and measures to identify, inform, educate, and enroll Providers established an eligibility screening tool to determine eligibility at intake for all clients every six months

40 Components of Procedures Clearly detailed and delineated procedures for education, enrollment and tracking for all clients Use existing systems (e.g., CAREware) to assess which clients need to complete applications Provider talking points for staff to use when talking to clients Tools to support procedures: Where clients can enroll and self-enroll Benefits of enrolling Consequences for not enrolling Eligibility information, etc. A toolkit for communication Tools for communicating (e.g., postcards- for distribution in English and Spanish) Presentations like "10 things RW clients should know about the ACA" Make all these tools available electronically (e.g., flash drives, etc.)

41 Components of Procedures (cont.) 41 Other Grantee examples: OUTREACH: Develop a "Dear Patient" letter outlining process changes and send out to clients ELIGIBILITY: Procedural details were provided which clarified what happens when clients do not meet eligibility requirements, choose not to enroll, or refuse to be screened for eligibility ENROLLING: Procedures were issued for ADAP Enrollment workers to track eligibility, enrollment, and recertification done electronically. Q&A document on eligibility screening and enrollment. Detailed information is provided for access and continuity of care with clarifying answers to questions. Q&A document on access to medication/pharmacy benefits through ADAP ONGOING TRAINING/TOOLS: A calendar of webinar trainings were provided for Enrollment Workers with TA and instructions for the screening process. Created a listing of health care services covered by payers and coverage/benefits plans

42 Ways to Rigorously Document Conduct continuous review of policy through programmatic monitoring Use existing systems to ensure proper client identification and tracking by payer source(s) (e.g,. qualified health plans, Medicaid, Medicare, etc.) Use Clients sign forms (e.g., Health Insurance Enrollment Acknowledgement) which confirms clients were properly educated and verified for all forms of coverage One EMA has a very robust approach to a training component for all ADAP Enrollment Workers and implementing their standard operating procedures. They provide very clear instructions to clients to ensure that continuity of pharmacy services under ADAP.

43 DUAL COVERAGE

44 RWHAP Coverage RWHAP funds may be used to pay for services received during the time between which a client enrolls in third party coverage and it becomes effective Once enrolled in a private health plan or Medicaid, RWHAP funds can be used for services not covered or partially covered by a client s plan

45 Covering Costs RWHAP funds generally may NOT be used to pay for services outside of their insurance network unless services are not available from an innetwork provider RWHAP funds may be used to pay for higher copays and deductibles within tiered networks Grantees must consider availability of resources prior to making such allocations

46 BUYING INSURANCE

47 General Guidelines for HAB Policies for Buying Insurance Encourages grantees to evaluate whether paying the cost for health care premiums or cost-sharing (such as co-pays or deductibles) is cost-effective and to pay it when grant funds are available Pharmaceutical benefits must be equivalent to the HIV antiretroviral and opportunistic infection related medication on the ADAP formulary as well as coverage for other essential medical benefits Grantees who plan to buy insurance should consider providing funds to the ADAP since many ADAPs have infrastructure to purchase insurance Funds for health insurance premiums and cost-sharing assistance are considered a core medical service

48 Recent Updates Revised Policy Clarification Notice (PCN) on formulary equivalency On June 6 th, HRSA released a revised PCN and that changes the formulary requirement that it, at a minimum, includes at least one drug in each class of core antiretroviral therapeutics from the HHS Clinical Guidelines for the Treatment of HIV/AIDS as well as appropriate primary care services Please note that grantees still need to do a cost-effectiveness analysis

49 Recent Updates (cont.) New Policy Clarification Notice (PCN) on reconciliation of Advance Premium Tax Credits On June 6 th, HRSA released PCN 14-01, which clarifies HRSA policy regarding the use of Ryan White HIV/AIDS Program funds to purchase health insurance for clients in the Marketplace and the reconciliation of advance premium tax credits RWHAP grantees and sub-grantees must vigorously pursue any excess premium tax credit a client receives from the Internal Revenue Service (IRS) upon submission of the client s tax return o Collect excess premium tax credit attributed to individual client

50 Recent Updates (cont.) PCN 14-01, continued HRSA is considering allowing RWHAP grantees and subgrantees to use RWHAP funds to pay the IRS any additional income tax liability a client may owe to the IRS solely based on reconciliation of the premium tax credit HRSA sought comments from the public regarding this proposed policy in a Federal Register Notice; comments are being reviewed. View the notice at 14/pdf/ pdf

51 Outreach and Enrollment THAT TIME OF YEAR AGAIN

52 Outreach and Enrollment Overview Open enrollment begins November 15, 2014, through February 15, 2015 In March 2013, HRSA s HIV/AIDS Bureau posted recommendations for RWHAP grantees on uses of existing funding to complete activities in the following three areas: outreach education, enrollment, and benefits counseling

53 Service Categories for Outreach and Enrollment RWHAP Parts A & B Early Intervention Services funding may be used for benefits counseling, enrollment, and outreach education RWHAP Parts C & D Medical Case Management Services funding may be used for benefits counseling and enrollment Medical Case Management Services funding may be used for benefits counseling and enrollment Non-Medical Case Management Services funding may be used for benefits counseling and enrollment Non-Medical Case Management Services funding may be used for benefits counseling and enrollment Health Education/Risk Reduction Services funding may be used for Affordable Care Act outreach education Outreach Services may be used for Affordable Care Act outreach education Outreach Services (PART C ) funding may be used for Affordable Care Act outreach education Referral for Health Care/Supportive Services funding may be used for benefits counseling, enrollment, and outreach education, as the Affordable Care Act is considered a benefit to PLWH Minority AIDS Initiative (PART B) funding may be used for outreach education, benefits counseling, and enrollment

54 Role of HIV Grantees Post-Enrollment Assist clients in applying for and enrolling in health care coverage o Role of assisters: Educate patients about what it means to have health insurance o Coverage to Care: Get in-network with Qualified Health Plans and Medicaid Managed Care Organizations ASAP o TARGET Center Provider Network Resources: o Answers About Health Plan Contracting Webinar Archive:

55 Affordable Care Act and Ryan White Program Resources Healthcare.gov: Assister Resources: HIV/AIDS Bureau Affordable Care Act and Ryan White Resources: Target Center Affordable Care Act Resources:

56 HAB ACA Cooperative Agreements The HIV/AIDS Bureau currently has three cooperative agreements providing technical assistance to grantees regarding the Affordable Care Act: Supporting the Continuum of Care: Building Ryan White Program Grantee Capacity to Enroll Eligible Clients in ACA Health Coverage Programs (ACE Project) John Snow, Inc. Engaging in Marketplace Insurance Plans under the Affordable Care Act Cicatelli Associates Establishing AIDS Service Organization (ASO) Service Models Fenway Community Health Connect Clients to New Plans Connect Medical Centers to Plans Connect ASOs to Medical Centers Maximize Continuum of Care Services Maximize Client Health Outcomes

57 THANK YOU! Laura Cheever Antigone Dempsey