ryan white moving forward and aca implementation san francisco provides access to healthcare – sf...
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Ryan White Moving Forward and ACA Implementation
San Francisco Provides Access to Healthcare – SF PATH
Celinda CantúData Administrator
San Francisco Department of Public HealthHIV Health Services
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Low Income Health Program (LIHP)
• San Francisco ‘s LIHP program is called SF PATH (“San Francisco Provides Access To Healthcare”)
• San Francisco’s LIHP is under the Department of Public Health• Provider network for SF PATH is Department of Public Health – same
network as Health Care Coverage Initiative under previous 1115 Waiver: • 16 primary care clinics (all FQHcs)
• 12 community oriented primary care clinics, including Tom Waddell, Castro Mission, Maxine Hall
• 4 hospital-based primary care clinics, including Ward 86:Positive Health Practice
• San Francisco General Hospital• Community Behavioral Health Services• Laguna Honda Hospital (short-term rehabilitation)
• SF PATH was approved by State and CMS, and implemented on July 1, 2011 – currently 10,000 enrollees in SF PATH
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Eligibility Criteria
• Ryan White • SF PATH
• Ryan White • (formally RW clients)
Ryan White SF PATH(formally RW clients)
Income: 0-400% FPL Income: 0% -133% FPL
SF Resident SF Resident
Legal Residency not considered
Documented citizenship or permanent legal resident (at least 5 years)
Government and other types of identification accepted
Government issued identification
No insurance or limited coverage Ineligible for Medi-Cal
HIV diagnosis No medical condition needed
No age restrictions Age: 19 – 64 years old3
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SF PATH Eligibility Determination for Ryan White ClientsIn
-P
erso
n
Scre
en
ing
En
try in
to
Ele
ctr
on
ic
Syste
m (
Oe
A)
Pre
-S
cre
en
ing
Ryan White Provider Completes SF PATH Pre-
Screening Form with Client at 6-Month Ryan White Re-determination
Completed SF PATH Pre-
Screening Form
Client Appears at SFGH, Bldg 10, 5th
Floor with Pre-Screening Form
Client Calls 415-206-8558 to schedule a SF
PATH Eligibility Determination
Appointment Scheduled
Application Assistor Reviews Client’s Documentation and
Pre-Screening Form to Determine Preliminary
Eligibility Preliminarily Eligible
Ineligible
Application Assistor Copies Notice, Provides Original to Applicant, Scans/Archives in Files, and Faxes to Referring
Ryan White Program
SF PATH Denial Notice
Completed
Full Application Determination in One-e-App
System Performed by Assistor with Client
Ineligible for SF PATH in One-e-App
SF PATH Denial Notice Completed
Application Assistor Copies Notice, Provides Original to Applicant, Scans/Archives in DPH Files, and Faxes to
Referring Ryan White Program
Client Enrolled in SF PATH
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HIV/AIDS Client Services Comparison for RW Eligible Clients Who Become/Are SF PATH or ACA Enrollee
ACA Services may include: Enrollee may become ineligible for these RW Core Service Categories:
Enrollee: Remains eligible for these RW Service Categories:
•Ambulance Services•Diagnostic and Laboratory•Durable Medical Equipment•Emergency & Post-Stabilization Services•Family Planning•Home Health Care•Hospital Care•Mental Health Care (outpatient and acute inpatient services)•Non-Emergency Medical Transportation•Outpatient Alcohol and Drug Treatment•Podiatry Care•Prescriptions (including ADAP/HIV medications)*•Preventive and Primary Care Services•Radiology•Short-term Rehabilitation•Specialty Care•Therapy (Occupational, Physical, Speech)•Urgent Care
*Disenrollment from ADAP is required for clients
Outpatient/Ambulatory Medical Care
Home Health Care
Medical Case Management (including Treatment Adherence)**
Outpatient Mental Health Services**
Outpatient Substance Abuse Services**
**Level of service provision and frequency TBD by state of CA
Ryan White Core Services:Oral Health Care – (Dental Services)***Facility-based Care (not acute hospital care)HospiceRyan White Support Services:Housing ServicesFood Bank/Delivered MealsPsychosocial ServicesLegal ServicesCase Management (Non-Medical):
Benefits CounselingMoney Management
Outreach ServicesEmergency Financial AssistanceResidential Substance Abuse Services***Oral Health Care may be reinstated as covered service with level & frequency TBD by state of CA
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LIHP Transition MilestonesTopic Milestone
Continue Stakeholder Engagement June – July 2013
Initial SF PATH Transition Notice to Enrollees
July 2013
Complete Data Transitions for Medi-Cal Managed Care
October 2013
Transition Health Care Coverage Initiative enrollee contact information to Covered California for Outreach
October 2013
Medi-Cal Managed Care Initial Plan Assignment Notice
November 2013
Administrative move of LIHP (SF PATH) Medi-Cal Coverage Expansion to Medi-Cal
December 2013
Covered California Open Enrollment Period Completed
December 2013
Medi-Cal Managed Care Plans & Covered California Qualified Health Plans Initiate Coverage
January 2014 6
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State ADAP Screening for LIHP• On March 1, 2012, the ADAP enrollment/recertification process,
accomplished through Ramsell (the ADAP statewide pharmacy benefits manager), began tracking client eligibility for SF PATH
• New enrollment forms that include SF PATH-related questions have been activated on the Ramsell ADAP enrollment website for San Francisco
• These forms require the ADAP Enrollment Worker to determine if the client may be eligible for SF PATH and track the client’s SF PATH application process
• Any ADAP applicant who may qualify for LIHP must be referred to apply to LIHP
• Access to the updated application can be obtained in the “Forms” section of the Ramsell secure website at: www.publichealthrx.com
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Post ACA Implementation populations that will continue to receive medical services through Ryan White Funding• Residually ineligible individuals (undocumented and those
documented with resident status of less than five years)• Other HIV populations at-risk to be under- served in capitated
care systems:• Patients with significant behavioral health issues
• At high risk for falling out of care• Often are 86-ed out of multiple programs• At higher risk for depression, chaotic substance use, violence and suicide than general
population• Have limited insight to modify behavior• Don’t meet criteria for “mental disability”• DSM5 Axis II “Personality Disorder” fixed traits or diagnosis
• Important to move beyond labels to see what is needed both for patient and system• Borderline is often over diagnosed and underdiagnosed• Often described as “low threshold patients”
• HIV elders
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Continuing Challenges
• Given uncertainty of RWPA funding in future years • Focus on sustainability- if RWP does decrease which
services could be integrated into emerging primary care system?
• Which services categories of service have funding streams in addition to RWP?
• Use Gardner Cascade as a tool to assist in determining service funding priorities
• Federal government is placing increased importance on clinical health care outcomes • what does the data show for what are considered
“support service categories”?
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Conclusions and Opportunities• CY 2014 is a unique opportunity to determine the best way for RWP
services and funding can wrap around ACA services• HHS can help ensure successful payer transitions while maintaining
continuity of care both of which will be a more immediate and on-going need
• HHS will focus on reviewing and potentially expanding services within a given service category as well as expanded and new uses of existing RW service categories
• HHSPC should sustain and improve the strength and coordination of multiple partnerships : • HIV Care and Prevention Services. • Consumer, Provider, Council and SF DPH
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