ACA Update Part 1:New Rules and Regulations

Federal AIDS Policy PartnershipAugust 7, 2013

Andrea Weddle, Co-chair HIV Health Care Access Working Group

Medicaid Expansion Benefits

• Referred to as “Alternative Benefits Package”• Regulation sets minimum standard – state flexibility

to develop robust package• Can develop different benefits packages for different

populations• “Medically Frail” population can choose traditional

Medicaid benefits – Definition broad - should include PWA

See Final Rule at http://www.ofr.gov/(X(1)S(le1fsc4mockmw1tkuddol4r5))/OFRUpload/OFRData/2013-16271_PI.pdf

Complicated Process

• State selects benchmark plan• Add EHB service if not covered • Add required Medicaid services• Option to submit Secretary-approved

coverage – States use if want traditional Medicaid benefits

Learn More: http://www.medicaid.gov/State-Resource-Center/Eligibility-Enrollment-Final-Rule/Alternative-Benefit-Plans-and-Essential-Health-Benefits.pdf

Retreat onDrug Coverage Requirement

• Minimum coverage = number of drugs covered by the benchmark for a drug class or at least one drug in a class, whichever greater

• Traditional Medicaid requires coverage of nearly all drugs

• Monthly drug limits and prior authorization allowed• Must have process for accessing drugs not on

formulary

Coverage for AntiretroviralsUSP ARV Drug Classes

USP Drug Count

Typical Drug Countfor Benchmark Plans

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors 4 5Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors 11 8Anti-HIV Agents, Protease Inhibitors 9 9Anti-HIV Agents, Other 3 3

See US Pharmacopia Drug Classification at: http://www.usp.org/usp-healthcare-professionals/medicare-model-guidelines

Will Combination ARVs be Covered?

New Medicaid Cost Sharing RulesIncome Under 150% FPL:• Up to $8 for non-preferred drugs; $4 for

preferred drugsPhysician can request non-preferred drug as

preferred with justification• Up to $4 for office visits• Up to $8 for nonemergency of the ER• Up to $75 for inpatient stays

Medicaid Cost Sharing II

• New rules apply to everyone – not just expansion population

• Under 100% not denied for failure to pay (still)• New HAB Guidance – Ryan White A B C D can

assist with Medicaid premiums & cost sharing depending on coverage adequacy and cost effectiveness

Take Away:State Advocacy Critical

– Educate state Medicaid on importance of comprehensive coverage for people with HIV–Urge coverage of ARVs according to federal

treatment guidelines, including combination ARVs–Comment on proposed Alternative Benefits

Package

For Details…

www.nastad.orgClick on “Health Reform” in the feature box

www.hivhealthreform.org

More Regulations/Guidance• Certified Application Counselor Guidance:

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CAC-guidance-7-12-2013.pdf

• Employer Mandate Delay Announcement: http://www.treasury.gov/connect/blog/Pages/Continuing-to-Implement-the-ACA-in-a-Careful-Thoughtful-Manner-.aspx

• Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions

http://www.ofr.gov/OFRUpload/OFRData/2013-15530_PI.pdf

• Eligibility for Minimum Essential Coverage for Purposes of the Premium Tax Credithttp://www.irs.gov/pub/irs-drop/n-13-41.pdfFor a translation of latest rules and policies – check out Timothy Jost’s Health

Affairs Blog: http://healthaffairs.org/blog/author/jost/

Enrollment - Training Resources

http://marketplace.cms.gov

New & Improved:• Tool to Evaluate Potential New Coverage

Options• State-specific Information• Coverage Information

Next HHCAWG Call:August 14th – 4 pm ETHIV/AIDS Bureau Call

on ACA Guidance:August 14th – 2:30 pm ET

55 Days Until Open Enrollment