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1 Resources and Links for Information on Health Care Reform and Its Implications for Safety Net Clinics and HIV Service Providers Updated April 2014 Previously updated for use in Texas under a subcontract with the University of Texas at Austin Health Care Reform Implementation Federal Programs and Resources [Includes information about these programs from both federal and other online sources] HealthCare.gov. This is the federal site designed to inform consumers about health care reform and the enrollment site for federally facilitated Exchanges/Marketplaces. See: Centers for Medicare and Medicaid Services: CCIO CMS s Center for Consumer Information and Oversight. See: Information about Essential Community Providers Insurance providers that offer plans in a Health Insurance Exchange or Marketplace are required under the Affordable Care Act (ACA) to include in their network a sufficient number and geographic distribution of providers that serve predominately low income, medically underserved individuals (referred to as Essential Community Providers (ECPs). At a recent webinar, CMS said the expected requirement for health plans for 2015 is inclusion in their networks of 30% of the ECPs in the health plan s service area, including one from each of the ECP categories. Frequently Asked Questions about Essential Community Providers Sheets and FAQs/Downloads/ecp faq pdf Non Exhaustive List of Essential Community Providers Exhaustive List of Essential Community Provide/ibqy mswq Information on Essential Health Benefits As of 2014, the ACA requires non grandfathered health plans to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices;(8) laboratory services;(9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care. These essential health benefits must be provided by both insurance EGM Consulting, LLC Page 1

2 companies offering policies in the Health Benefit Exchange or Marketplace, and by Medicaid programs for individuals who become Medicaid eligible due to Medicaid expansion. See: Resources/ehb.html Enrollment Assister Programs Three kinds of assisters help people learn about and enroll in the ACA Marketplaces, whether federal, state federal partnerships, or state run. They are navigators, in person assisters, and Certified Application Counselors (CACs). For a summary of assister programs, see: to help.pdf Organizations Funded to Provide Navigation Services CMS funded 105 organizations to provide navigators in the states with federally facilitated exchanges (including Virginia) or federal state partnerships. The list, organized by state, includes at least two entities in each state, at least one of them a community based entity. The funding allocations for the states include a $50,000 base amount plus an amount that represents that state s proportion of all uninsured individuals in those states. See: and Initiatives/Health Insurance Marketplaces/ Downloads/navigator list pdf In addition, nearly all FQHCs were funded to provide navigators, and the funding has been added to their core grants; the Bureau of Primary Health Care (BPHC) has indicated that the funding will be ongoing. For a list of these grants, see: For the plans to continue those grants, see: Certified Application Counselors (CACs) In states with federally facilitated marketplaces, nonprofit organizations can apply to CMS to become Certified Application Counselor (CAC) organizations. States that run their own Marketplaces are also required to have a CAC program. Five hours of federal training is available online; states may choose to provide their own training. Ryan White providers are specifically identified as potential CAC organizations. Trained staff cannot do outreach but can assist clients with enrollment. A description of the CAC program is available at: us/cac.html For additional FAQs about the CAC program, see: us/common qandas about cac designation.pdf The organization needs to apply; the application is online at: us/cac apply.html Enroll America has a useful fact sheet on CAC programs: EGM Consulting, LLC Page 2

3 CMS Medicaid Chronic Disease Health Homes. CMS is providing two year 90% match funding to states to develop pilot health homes for individuals with chronic diseases. The program is explained in the Guide to Medicaid Health Home Design and Implementation at: Resource Center/Medicaid State Technical Assistance/Health Homes Technical Assistance/Guide to Health Homes Design and Implementation.html The Commonwealth Fund also has a concise and informative summary of health homes, Health Homes for the Chronically Ill: An Opportunity for States, at: in Action/2011/Jan/December 2010 January 2011/Feature/Feature.aspx Research Briefs from the Office of the HHS Assistant Secretary for Planning and Evaluation (ASPE). These briefs come out almost every month and address varied topics, from projected eligibility of uninsured people from certain populations (e.g., African Americans, Latinos, Asian Americans) to metrics for measuring the effects of ACA on safety net hospitals. An index of recent Research Briefs is available at Research/index.cfm. Several types of Research Briefs are described below. HHS Reports on Enrollment in the Marketplace. HHS provides monthly updates on enrollment in the Marketplace nationally and by state. The report covering enrollment through the first open enrollment period is Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Enrollment Period: October 1, 2013 March 31, 2014 (Including Additional Special Enrollment Period Activity Reported through ), along with two Addenda with additional state by state data. It and other ASPE Issue briefs, can be accessed through: Research/index.cfm Immigrants and the ACA. There are several briefs on immigrants, including the 2012 The Affordable Care Act: Coverage Implications and Issues for Immigrant Families, which is available at Bureau of Primary Health Care. BPHC has provided funding to nearly all the community health centers/federally qualified health centers (CHCs/FQHCs) in the country to provide navigators and related assistance in outreach and enrollment. An interactive map that provides funded entities by state can be found at: HIV/AIDS Bureau. To help guide Ryan White grantees, planning bodies, and providers understand their roles in relation to Marketplace outreach and enrollment and in care coordination and completion, HAB has issued seven policy notices and provided webinars. Policy Notices include the following, and are at Uniform Standard for Waiver of Core Medical Services Requirement for Grantees Under Parts, A, B, and C EGM Consulting, LLC Page 3

4 13 06 Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost Sharing Assistance for Medicaid Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost Sharing Assistance for Private Health Insurance Clarifications Regarding Clients Eligible for Private Health Insurance and Coverage of Services by Ryan White HIV/AIDS Program Ryan White HIV/AIDS Program Client Eligibility Determinations: Considerations Post Implementation of the Affordable Care Act Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements Clarifications Regarding Medicaid Eligible Clients and Coverage of Services by Ryan White HIV/AIDS Program Webinar. A number of on demand webinars are available on the HRSA/HAB website. They address standards for waivers of the requirement that 75% of Part A, B, and C program funds be used for core medical related services, ACA in states that are not expanding Medicaid, and Policy Notices through 13 06, among other topics. They can be accessed at: The TARGET Center, HIV/AIDS Bureau. This website, developed to support Ryan White programs, grantees, and PLWH, has an increasing number of materials on health care reform with an HIV focus but often useful for other safety net health care providers. Do a search on health care reform and a variety of useful materials will appear. It includes some specific tools and other resources developed EGM Consulting and other entities See: and look for: EGM Consulting s self assessment and planning tool for HIV and other providers, particularly those that provide behavioral health or support services rather than primary medical care. Includes six tools for use by staff and Board in planning for health care reform implementation. See: aca tools hiv service providers Agency Readiness for TA, a set of materials collected and placed on the TARGET Center website and dated May Included are materials ranging from Health Reform Readiness Index Resources: A Provider Change Guide to HIV Service Organizations: Planning Considerations for the ACA Transition. See: readiness aca Materials to help safety net clinics that are not community health centers or federally qualified health centers prepare for health care reform. Developed by Mosaica and EGM Consulting, LLC as its subcontractor, through the Protecting the Safety Net Project, funded by Kaiser Permanente of the Mid Atlantic Region, and updated by EGM Consulting several times in 2013 and See for example, Protecting the Health Safety Net: Models to Help Non FQHCs Prepare for Health Care Reform Implementation, at: EGM Consulting, LLC Page 4

5 health safety net models help non fqhcs prepare health care reformimplementation The Commonwealth Fund s Affordable Care Act: Supporting Implementation, which identifies a number of federal entities and resources, many useful for all types of healthcare providers including FQHCs. See: care act supporting implementation The University of Wisconsin s Health Reform Readiness Index Resources: A Provider Change Guide, available at: State Information District of Columbia Maryland General information about health care reform in DC through the DC Health Benefit Exchange, including information about meetings, outreach efforts, and implementation: DC Health Link, the online marketplace that describes available health plans and provides for online enrollment: DC Marketplace Health plan rates, individuals: dividualrates71913.pdf Health plan rates, small business: mallbusinessrates71913.pdf List of 35 local organizations funded by the DC Health Benefit Exchange in August 2013 to manage enrollment assisters : sites/health%20benefit%20exchange%20 Authority/release_content/attachments/ hbxgranteesnew.pdf Health plan rates, individuals: attachments/finalindividualrates71913.pdf Health plan rates, small business: disb/publication/attachments/finalsmall BusinessRates71913.pdf Description of the development of DC s health benefits exchange: reform/state profile/state exchange profiles district ofcolumbia/ General information about health reform and implementation in Maryland: EGM Consulting, LLC Page 5

6 Virginia Maryland Health Benefit Exchange, with information about planning and implementation: Maryland Health Connection, the online marketplace to be used by individuals/families and small businesses for choosing an insurance plan within the Exchange: Health plan rates for 2014: For individuals: health connection plansindividual.html For small businesses (SHOP): health connection plansshop.html Report that compares Maryland individual market rates with those of other states that had announced plans and rates by July 2013: content/uploads/2013/07/analysis of Individual Market Rates for Health Plans on Maryland Health Connection.pdf Description of the development of Maryland s Exchange, including federal funding; reform/state profile/state exchange profiles maryland/ General information about health care reform: Federal enrollment site: Information about Virginia s decision in February 2013 to perform health plan management activities, even though the State did not enter into a federal state partnership to operate an Exchange, and the federal grants received to support such activities; provided in the Kaiser Family Fund profile on Virginia. See: reform/state profile/state exchange profiles virginia/ Information about Virginia s recommendations to the federal Exchange at CMS regarding individual/family and small business plans (news article): regional/va oks health plans for newexchange/article_f54b3af4 fb3d 546b b5f8 e35f37ba68ed.html Other National Sources KFF Health Reform Source. Website maintained by the Kaiser Family Foundation, with numerous reports and updates, issue briefs, and analyses. Provides national and state by state information on health care reform implementation, including health insurance exchange decisions and progress, grants received, Medicaid and Medicare changes, etc. See reform/. Some particularly useful website features: EGM Consulting, LLC Page 6

7 State Exchange Profiles. Provides a narrative description of each state s actions and progress on health insurance exchange planning and implementation, see: reform/state profile/state exchange profiles. Health Reform FAQs: For extremely thorough FAQs about numerous aspects of health care reform, see reform/faq/health reform frequently askedquestions/. State Refor(um). Website maintained by the National Academy for State Health Policy as an online network for health reform implementation. Individuals and agencies can register and join discussions as well as access state and national materials. Many materials are posted and shared, and there are groups that focus on particular aspects of health care reform. You can join and become part of various discussion groups and view progress and challenges by state. For example: Reports of Note State by state progress is provided. NASHP monitors progress each state has made towards 109 milestones related to health care reform implementation. Website address is: to review a state s activities related to various aspects of implementation as well as Marketplace plan premium rates, go to: and click on the state of interest, using the map provided. State decisions and actions on Medicaid expansion, number of uninsured, and fiscal and demographic analysis are available at: decisions?gclid=cmoxwpuitbgcfrca4aodnkqapg Essential Community Providers: Tips to Connect with Marketplace Plans. Practical information to help community based providers make contact with health insurers in order to become members of their networks. Available at: Medicaid Expansion The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State by State Analysis. John Holahan, Matthew Buettgens, Caitlin Carroll, and Stan Dorn. Prepared by the Urban Institute for the Kaiser Commission on Medicaid and the Uninsured, November See press release, executive summary, and full report at reform/report/the cost and coverage implications of the/. This report projects numbers of people likely to be eligible for and covered by Medicaid expansion, by state, and cost implications showing the financial benefits of Medicaid expansion. Lessons from Early Medicaid Expansions under Health Reform: Interviews with Medicaid Officials. Benjamin D. Sommers, Emily Arntson, Genevieve M. Kenney, Arnold M. Epstein, Harvard School of Public Health Department of Health Policy & EGM Consulting, LLC Page 7

8 Management. In CMS Medicare & Medicaid Research Review, 2013: Volume 3, Number 4. Available at: Provides lessons from the District of Columbia and five states that chose to implement Medicaid expansion before January 1, Undocumented and Uninsured: Barriers to Affordable Care for Immigrant Populations. Prepared for the Commonwealth Fund by the UCLA Center for Health Policy, this report, released August 15, 2013, focuses on California but addresses a national challenge. It estimates that more than 60% of the undocumented nationally will remain uninsured as ACA is implemented and that they will account for up to 40% of remaining uninsured residents nationally. This will put considerable pressure on safety net hospitals as disproportionate share (DSH) payments are reduced, threaten the sustainability of many safety net primary care providers, and negatively affect population health. The report looks at access to care for this population and how it might be improved. See: Reports/2013/Aug/ Undocumentedand Uninsured.aspx Clinic Collaboration and Mergers The California HealthCare Foundation has documented clinic collaboration and merger efforts in California, and prepared issue briefs and case studies with lessons learned and factors to consider. See clinics. Among the publications addressing collaboration and mergers are the following: Testing the Waters: Five California Clinics Explore Strategic Restructuring. Case Studies, February Describes how five clinics explored collaboration or other strategic restructuring over a two year period, with help from the Foundation. Available at: waters clinicsrestructuring Merging Ahead: Case Studies in Clinic Consolidation. Issue Brief, November Provides three case studies on successful and failed merger efforts, including lessons learned, along with benefits and challenges. Includes diverse internal and external perspectives. Available at: aheadcase studies in clinic consolidation Strategic Restructuring for California Community Clinics: Self Assessment Workbook. September Addresses readiness for restructuring, including collaboration and mergers. Strategic Restructuring: Information and Resources for California Community Clinics. September Includes case studies of several types of collaboration as well as mergers, along with lessons learned. Both available at: Available at: restructuring assessment EGM Consulting, LLC Page 8

9 HIV/AIDS and Health Care Reform Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People with HIV. Kaiser Family Foundation, Issue Brief, January Written by Jennifer Kates et al. Available at brief/assessing the impactof the affordable care act on health insurance coverage of people with hiv/. This issue brief uses CDC Medical Monitoring Project (MMP) data to assess the number of people with HIV who are likely to benefit from ACA coverage. It estimates that about 87% of the 407,000 people with HIV aged who are in care have incomes below 400% of the federal poverty level (FPL). While about 40% have Medicaid coverage, nearly 70,000 (17%) are currently uninsured; almost 23,000 could obtain coverage through the Marketplace, and most are eligible for financial assistance. Another 46,910 would be eligible for Medicaid if all states expanded the program, but more than 40% are in states that have not indicated plans to expand Medicaid. These PLWH will remain dependent on Ryan White services and the program will also continue to fill important coverage gaps for individuals with public or private insurance. Another 124,000 PLWH who are not in care should be eligible for Marketplace coverage, which means about 200,000 PLWH could eventually gain coverage as a result of ACA. Ryan White ADAP Client Eligibility for Medicaid and the Exchange, and Comparisons of Covered Services and Medications. Harvard Law School, Center for Health Law and Policy Innovation, and Treatment Access Expansion Project, State Health Reform Impact Modeling Project: Texas, January Available at: Modeling Report Final.pdf The report charts the estimated number and percent of Texas ADAP clients who qualify for coverage under the Medicaid expansion or Exchange. It also provides a chart of services covered by Ryan White, Medicaid, and the Benchmark Health Plan to be used in the Exchange. It identifies service and medication gaps in Medicaid and the Exchange compared to Ryan White, and the probable ongoing need for Ryan White for care completion ensuring continued access to comprehensive core medical related and support services necessary to link people living with HIV to care, retain them in care, and attain viral suppression. Reports are available for 21 states and the District of Columbia. The Affordable Care Act and HIV/AIDS Two very informative analyses by Jeff Crowley (former Director of the Office of National AIDS Policy) and Jen Kates: The Affordable Care Act, the Supreme Court, and HIV: What are the Implications? Policy Brief, Kaiser Family Foundation, September Available at: Includes detailed charts of implementation timing and a very clear description of the opportunities and challenges of making sure people living with HIV receive comprehensive, high quality, appropriate care under ACA. EGM Consulting, LLC Page 9

10 Updating the Ryan White HIV/AIDS Program for a New Era: Key Issues & Questions for the Future, Kaiser Family Foundation, April Available at: Discusses four key issues and potential program changes for the Ryan White program: (1) supporting people with HIV at each stage of the treatment cascade, from diagnosis to viral suppression; (2) building HIV care networks in underserved communities; (3) integrating HIV care expertise into the mainstream health care system; and (4) effectively and fairly allocating Ryan White resources. HIV/AIDS and Medicaid Strategies for Coordination between Medicaid and Ryan White HIV/AIDS Programs. This policy brief from the National Academy for State Health Policy (NASHP), issued in November 2013, describes the importance of coordination between Medicaid, the primary source of health coverage for most PLWH, and Ryan White programs, which helps provide access to comprehensive care for PLWH. The brief is based on NASHP interviews with Medicaid and Ryan White officials in 14 states, including Texas, about successful coordination efforts. It suggests promising practices for coordination that improve service delivery for PLWH. See: between medicaid and ryan white hivaids programs Related Information Federal Poverty Guidelines, 2013 and 2014 Federal Poverty Guidelines are the annually determined income limits often used to determine eligibility of federal programs and services, including Medicaid Expansion and federal subsidies to individuals who purchase insurance through a Health Benefits Exchange or Marketplace. For the second enrollment period 2014 guidelines will be used. These charts include poverty guidelines for 100%, 133%, 200%, 250%, 300%, and 400% of the federal poverty level for 2014 and for Included are annual and monthly income limits. For 2013 guidelines, which applied through the first enrollment period, see data from the Georgetown University Health Policy Institute, Center for Children and Families, at Federal Poverty Guidelines1.pdf. For 2014 guidelines, which will apply during the next open season for Marketplace enrollment, see Medicaid charts, available at: CHIP Program Information/By Topics/Eligibility/Downloads/2014 Federal Poverty level charts.pdf Culturally and Linguistically Appropriate Service Requirements for Health Insurance Providers The Public Health Services Act (PHS) section 2719 requires non grandfathered group health plans and health insurance issuers offering non grandfathered health insurance coverage to provide relevant notices in a culturally and linguistically appropriate manner. The regulations implementing section 2719 require these plans and issuers to make certain accommodations for notices sent to an address in a county where at least 10% of the population is literate only in EGM Consulting, LLC Page 10

11 the same non English language. For counties throughout the country that met this requirement as of 2012, see: Sheets and FAQs/clas data.html EGM Consulting, LLC Page 11