THE AFFORDABLE CARE ACT AND THE RYAN WHITE HIV/AIDS PROGRAM

NEW OPPORTUNITIES FOR PEOPLE LIVING WITH HIV/AIDS

PRESENTATION BY:HEALTH RESOURCES AND SERVICES

ADMINISTRATIONCENTERS FOR MEDICARE AND MEDICAID

SERVICES

APRIL 5, 2013

Purpose of Webinar

Educate Ryan White grantees about how the ACA helps people living with HIV/AIDS (PLWH) get health coverage

Review new Medicaid coverage options CMS - Center for Medicaid and CHIP Services (CMCS)

Review new private coverage options CMS – Center for Consumer Information and Insurance

Oversight (CCIIO) Outline new enrollment and eligibility verification

process CMS and CCIIO

Review what HIV providers need to know HRSA – HIV/AIDS Bureau & Office of Policy Analysis and

Evaluation

Health Coverage Options for PLWH BEFORE the Affordable Care Act

Note: Data only reflective of Ryan White clients, not of entire HIV/AIDS population; Source: 2010 Preliminary Ryan White Services Report Data (RSR)

ACA: Increased Access to CoverageACA: Increased Access to Coverage

Provides new opportunities for State Medicaid programs to cover additional adults with low incomes, and simplifies the eligibility rules for Medicaid and CHIP

Establishes Health Insurance Marketplaces to help individuals purchase health insurance coverage (major medical and stand-alone dental) Provides for advance payments of the premium

tax credit and cost-sharing reductions to help certain low-income individuals afford health insurance purchased through a Marketplace

Establishes one streamlined process for eligibility

Health Coverage Options for Individuals in 2014Health Coverage Options for Individuals in 2014

133% FPL Adults

400% FPL

250% FPL Cost-Sharing

Reductions

Percent of Federal Poverty Level

Advance Payment of the Premium Tax Credit

CHIPFPL varies by State

Qualified Health Planswithout Financial Assistance

133% FPL

400% FPL

250% FPL

Medicaid (optinal)Medicaid

Medicaid in 2014

Simplified Medicaid and CHIP eligibility and enrollment

Expanded Medicaid eligibility

Adult group

100% federal funding from 2014 – 2016; gradually moves to 90% in 2020 and beyond for new adult group

Move to MAGI for most individuals

Standards to ensure coordinated, accurate, and timely processing of eligibility determinations and data sharing to other agencies administering insurance affordability programs

Renewals every 12 months for many

Minimum Medicaid Eligibility Levels:

Now and 2014Population Current Minimum

Eligibility Levels2014 Minimum

Eligibility Levels

Children & Pregnant Women

100%/133%(Average =241%)

≥ 133%(Varies by state)

Parents Varies by state(Average = 64%)

133%

Disabled Adults 74%(SSI-related)

133%

Other Adults 0%* 133%**

*Five states provide Medicaid or Medicaid look-alike coverage to certain childless adults; 15 states provide a limited benefit package to certain childless adults. **In states that cover new mandatory group.

Market Reforms: OverviewMarket Reforms: Overview

Fair Health Insurance Premiums

Health status and gender not used to set premiums; limits on age

rating

Single Risk PoolIssuers cannot use separate risk

pools to charge certain customers higher rates

Guaranteed AvailabilityCoverage must be offered to all comers, with limited exceptions

Guaranteed RenewabilityCoverage must be renewed for all

policyholders, with limited exceptions

Market Reforms

The market reforms collectively ensure that individuals and employers will have a minimum set of protections with respect to access to health

insurance coverage and greater premium stability in all States, both inside and outside the Marketplace.

“Marketplaces” were established by the Affordable Care Act (ACA)

New commercial insurance marketplace where eligible small businesses and qualified individuals can shop for private health insurance plans

Consumers will have more choice and selection in health plans access to assistance that will help make coverage more

affordable

Enrollment starts October 1, 2013 Coverage starts January

1, 2014

What is the Health Insurance Marketplace?

Each State can choose to: create and run its own Marketplace: State-Based

Marketplace (SBM) partner with the Federal government to run some

Marketplace functions: State Partnership Marketplace (SPM)

have a Marketplace that’s operated by the Federal government: Federally-Facilitated Marketplace (FFM)

State grant funding to establish a SBM is available through 2014

State Marketplace Options

Financial Assistance - Individual MarketFinancial Assistance - Individual Market

Advance premium tax credits: Will reduce the premium amount an individual owes each

month Available to eligible individuals with household incomes

between 100% and 400% of the FPL ($45,960 for an individual and $94,200 for a family of 4 in 2013), and who don’t qualify for other health insurance coverage providing “minimum essential coverage”

Based on household income and family size for the taxable year

Paid each month by the Federal government to the insurer

Reconciled on the taxpayer’s tax return after end of year

Financial Assistance - Individual MarketFinancial Assistance - Individual Market

Cost-sharing reductions: Reduces out-of-pocket costs (deductibles,

coinsurance, copayments) Generally available to those with income between

100% ($11,490 for an individual and $23,550 for a family of 4 in 2013) and 250% FPL ($28,725 for an individual and $58,875 for a family of 4 in 2013)

Also available to American Indians/Alaska Natives who meet the statutory definition of “Indian”

Based on household income and family size for the taxable year

Qualified Health Plans (QHPs) must be certified to be offered in a Marketplace. Must meet certain minimum standards.

QHPs will be standardized in 4 coverage tiers with varying actuarial values (percentage of the total allowed cost of benefits paid by an insurance plan) or be a catastrophic plan, available for certain eligible individuals:

Insurers in the Marketplace: “Qualified Health Plans”

Levels of Coverage Actuarial Value

Bronze 60 percent

Silver 70 percent

Gold 80 percent

Platinum 90 percent

Qualified Health Plans and Essential Community Providers

Essential community provider (ECP) are providers who serve predominantly low-income, medically underserved individuals.*

“A QHP issuer must have a sufficient number and geographic distribution of essential community providers…”

On March 26, CMS/CCIIO posted a “non-exhaustive list” of ECPs to assist health insurance issuers in locating ECPs:

http://cciio.cms.gov/programs/exchanges/qhp.html.

*ECPs include health care providers defined in section 340(B)(a)(4) of the Public Health Service Act and described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act.

Essential Community Providers

In 2014, CMS will use a tiered approach to ensure that QHP provider networks meet network adequacy requirements, including the integration of essential community providers:

Safe harbor standard: at least 20 percent of available ECPs in the plan’s service area participate in the issuer’s provider network(s). In addition, the issuer agrees to offer contracts before the coverage year to:

All available Indian providers; and One ECP per type, per county (where available).

Minimum expectation: at least 10 percent of available ECPs in the plan’s service area participate in the issuer’s provider network(s). In addition, the issuer must submit a narrative justification as part of the QHP Application.

Issuers that provide a majority of covered services through employed physicians or a single contracted medical group will be evaluated based on the same percentages, applied to the issuer’s provider locations in certain areas.

Essential Community ProvidersPotential Scenarios

Issuers A, B, and C propose service areas in which 80 ECPs are available.

• Issuer A’s network includes 16 ECPs. Issuer A attests that it has offered contracts to available Indian providers and one ECP in each major ECP category. Issuer A meets the safe harbor standard; no additional documentation is required.

• Issuer B’s network includes 8 ECPs. Issuer B provides a narrative justification explaining why its network includes only 8 ECPs and how it will ensure service for low-income and medically underserved enrollees. Issuer B meets the minimum expectation.

• Issuer C’s network includes 10 ECPs. Issuer C fails to provide a narrative justification. Issuer C does not meet the minimum expectation and will receive a deficiency notice from CMS.

• For an issuer that does not meet either the safe harbor standard or the minimum expectation, CMS will expect the issuer’s application to include a narrative justification describing how the issuer’s provider network(s) will provide access for low-income and medically underserved enrollees and how the issuer plans to increase ECP participation in the issuer’s provider network(s) in future years.

Single, streamlined application for enrollment in a QHP through the Marketplace and all insurance affordability programs

Website that provides program information and accepts the single, streamlined application

Coordinated verification policies across Medicaid, CHIP and the Marketplaces (e.g. income, State residency, requesting SSNs)

Standards and guidelines for ensuring a coordinated, accurate and timely process for performing eligibility determinations and transferring information to other agencies administering insurance affordability programs

How will PLWH apply for new coverage?

• Online• Phone• Mail• In Person

Submit single, streamlined

application to the Marketplace, Medicaid/CHIP

• Supported, in part, by the Federally-managed data services hub

• Eligibility for: • Medicaid and CHIP• Enrollment in a QHP• Advance payments of

the premium tax credit and cost-sharing reductions

Eligibility is verified and determined

•Online plan comparison tool available to inform QHP selection

•Advance payment of the premium tax credit is transferred to the QHP

•Enrollment in Medicaid/CHIP or QHP

Enroll in affordable coverage

Streamlined Eligibility and Enrollment Process – Medicaid and Marketplace

Increased reliance on self-attestation Primary reliance on electronic sources A single electronic source for multiple

verifications- “the Hub” Local data sources will also be used

Decreased reliance on paper documentation May not be the primary source of verification when

electronic data sources exist, and may only be requested when electronic data is unavailable or not reasonably compatible

A Streamlined Approach to Verification

Marketplace makes Medicaid/CHIP MAGI eligibility determinations using State Medicaid/CHIP eligibility rules and standards

OR Marketplace makes initial assessment of

Medicaid/CHIP eligibility; State Medicaid and CHIP agencies make the final eligibility determination

*For further information regarding options for conducting eligibility determinations, see 45 C.F.R. 155.302

Options for Coordinated Eligibility Determinations through Marketplaces

When Can Individuals Enroll?When Can Individuals Enroll?

First Open Enrollment October 1, 2013 - March 31, 2014 First coverage date is January 1, 2014 for plan

selections made by December 15, 2013

Annual Open Enrollment October 15 - December 7 Coverage begins January 1 of the next year

Consumers eligible for Medicaid and CHIP can enroll at anytime

When Can Individuals Enroll?(cont’d)When Can Individuals Enroll?(cont’d)

Certain events may allow eligible consumers

to enroll during a Special Enrollment Period

1. Loss of minimum essential coverage

2. Marriage, birth, or adoption

3. Gain citizenship or qualifying immigration status

4. Enrollment errors5. Plan violates their

contract

6. Gain or lose eligibility for tax credits or cost- sharing reductions

7. Gain access to new plans as a result of a move

8. Status as an Indian9. Exceptional

circumstances10. Enrolled in non-

qualifying employer coverage

Ryan White HIV/AIDS Program - still the Payer of Last Resort

“funds received…will not be utilized to make payments for any item or service to the extent that payment has been made, or can reasonably be expected to be made…”

At the individual client level, this means that grantees are expected to make every reasonable effort to secure other funding instead of Ryan White HIV/AIDS Program funds whenever possible

The RWHAP will continue to pay for items or services received by individuals who remain uninsured or underinsured

Recap: Pathways of Coverage for PLWH

Medicaid

Medicare

Employer-Based

Insurance

Health Insurance Marketpla

ce

Other Public

Other Private

Ryan White Progra

mCover comprehensive HIV medical and support services not covered by public programs or private insurance

Cover comprehensive HIV medical and support services not covered by public programs or private insurance

PLWH eligible for health coverage

PLWH who remain uninsured

Premium Sponsorship: Aggregation of Premium Payments

State-based Marketplaces (SBM) have the flexibility to implement a process for premium payment aggregation

Organizations/entities are able to work with issuers or SBMs to establish a premium sponsorship process that facilitates the aggregation of premium payments for a group of individuals The utilization of an organization’s/entity’s funds for such

premium payments may be subject to federal and/or state laws, and/or agency procurement policies and may be used if permissible under law and in accordance with policy

The Federally-facilitated Marketplace (FFM) will not be able to establish a process that would facilitate premium sponsorship or facilitate the ability for organizations to pay premiums on behalf of individuals for Oct. 1, 2013; any third-party payments in the FFM will need to occur through direct work with individuals or issuers

What HIV Providers Need to Know Many PLWH will move to new health coverage options Marketplaces (private coverage):

QHPs are not required to contract with all HIV providers

Your practice must have appropriate IT and billing infrastructure to participate in plans

Open enrollment for Marketplaces begins October 1, 2013 - make sure you are in-network!

Medicaid: RWHAP providers do not determine a client’s

eligibility for Medicaid- only Medicaid makes final eligibility determinations for participation in Medicaid

To-Do List for HIV Providers

Get Involved in Planning Research what’s going on in your state:

healthcare.gov/law/information-for-you cciio.cms.gov/resources/factsheets/state-marke

tplaces.html Participate in your local Ryan White

Planning group: careacttarget.org/community

Get regular updates from HRSA: hab.hrsa.gov/affordablecareact

To-Do List for HIV Providers

Maximize Payer Options Private Insurance / Marketplaces

Find out more about QHPs and provider credentialing requirements via your State Insurance Commissioner:

www.naic.org/state_web_map.htm Contact the top three insurers in the small group market in

your state to join new networks: cciio.cms.gov/resources/files/largest-smgroup-products-7-2-201

2.pdf.pdf

Medicaid Contact your state Medicaid office to join new networks:

www.medicaid.gov/medicaid-chip-program-information/by-state/by-state.html

Review third-party billing systems and seek TA as necessary

targethiv.org/category/topics/fiscal-management

Where Can I Obtain Additional Information? Where Can I Obtain Additional Information?

HHS www.healthcare.gov

CMS – Medicaid Medicaid.gov

CMS – CCIIO cciio.cms.gov

HRSA hab.hrsa.gov/affordablecareact/index.html

For any questions related to RW and the ACA, please email: RWP-ACAQuestions@hrsa.gov