Health Care Reform W H A T D O E S I T M E A N F O R P E O P LE - - PowerPoint PPT Presentation

W H A T D O E S I T M E A N F O R P E O P LE W I TH H I V ? O v e r c o m i n g H e a l t h D i s p a r i t i e s i n t h e Ca l i f o r n i a B a y A r e a U s i n g H I V / A I D S a s a M o d e l

S a n F r a n c i s c o M a y , 2 0 12

A N N E D O N N E L L Y P R O J E C T I N F O R M A D O N N E L L Y @ P R O J E C T I N F O R M . O R G 4 1 5 . 5 5 8 . 8 6 6 9 X 2 0 8

Health Care Reform

Presentation Outline

 Part One: Considering Disparities  Part Two: The Supreme Court and Elections  Part Three: Turning Back?  Part Four: Health Care Reform and a Changing

HIV/ AIDS Care Landscape

 Part Five: California at the Crossroads  Part Six: Priorities for ACA Implementation

Health Care Reform and Disparities

Health Education and Prevention

• How will

PLWHA get information?

• Assistance?

Diagnosis and Linkage to Care

• What

supports/ services are necessary?

• Who pays?

Treatment and Retention in Care

• Formularies?
• Benefits

Packages?

• Wrap Arounds?

W H A T W I LL H A P P E N W I TH H E A LTH CA R E R E F O R M ?

The Supreme Court and Elections

The Supreme Court: What Could Happen?

Opponents challenged constitutionality of the individual mandate and the Medicaid expansion and SCOTUS heard arguments in

• March. Decision is expected in June

The entire law survives The individual mandate is struck down, but some parts

• f the law survive

The entire law is struck down

2012 Elections = Watershed for Health Care

Will the ACA be fully implemented? Will deficit reduction be achieved responsibly? Will our health care safety nets (Medicaid, Medicare, Ryan White Program) be preserved?

Control of the White House Control of the House Control of the Senate

T H E S Y S T E M I S B R O K E N

Can We Afford to Turn Back?

Broken Systems: Access to Care Crisis

30% of people living with HIV are uninsured Thousands

• n ADAP

Waiting List Demand for Ryan White Services is Growing 42 – 59% of low income PLWH are not in regular care People with HIV can’t get insurance coverage

The Current Crisis

Health Care Reform – A Changing Care Landscape

 Creates an individual mandate that citizens must

carry health insurance

 Financial penalties apply to those who do not  Exemptions for hardship and some other reasons  Individual mandate under attack; many still think it will be

upheld

 Coverage expansions are – in effect – a mandate for

people with HIV who want to stay in care

 Ryan White payer of last resort rules

New Responsibilities

Coverage Expansions

Estimated 3 32 Milli illion will g ill gain in cove verage b by 2019 Medicaid: 16 million Income Under 138% FPL Exchange: 26 million Income above 138% FPL

Medicaid: Improved and Expanded

 Currently Medicaid is – for most with HIV –

disability coverage

 In 2014:

 Expanded Eligibility The disability requirement is eliminated Most people with income up to 138%FPL will be eligible

for Medicaid/ Medi-Cal (appr. $15K for an individual)

No asset test  Could Improve Services Medicaid expansion includes Essential Health Benefits

(EHB) for newly eligible people

Improves Access to Private Insurance

Insurance Reforms State-Based Exchanges

• Consumer friendly

marketplace to purchase private insurance

• Federal subsidies for

people with income up to 400% FPL

• Plans must provide

essential health benefits

• Can’t be denied or dropped from insurance

because of HIV (all plans)

• Can’t be charged higher premiums because
• f HIV or gender (exchange plans)
• No more lifetime and annual limits (all

plans)

• Prevention services (including routine HIV

testing for women) must be covered without cost sharing (all plans)

• Caps amount spent out of pocket

(exchange plans)

Increases Access to Medicare Part D

 50% discount on all brand-name

prescription drugs

 AIDS Drug Assistance Program

(ADAP) contributions now count toward copayment obligations, allowing people with HIV to move through the “donut hole”

 Part D “donut hole” phased-out by

2020

Improvements in MH and SUD Services

 Mental health (MH) and substance use disorder (SUD) tx

part of EHB

 Mandatory coverage for MH and SUD at parity  New opportunities in primary care and integrated

services

 Primary care, MH and SUD community health team grants;  Centers of excellence for depression  MH and SUD providers on team in Medicaid medical homes

 No cost preventative services include some mental health  Projects at CMMI include mental health  Provider non-discrimination provisions

New Mandatory Package of Benefits

Essential Health Benefits

 Ambulatory services  Emergency services  Hospitalization  Maternity/ newborn care  Mental health and substance use tx services – to parity  Prescription drugs  Rehabilitative and habilitative services  Laboratory services  Preventive and wellness services and chronic disease

management

 Pediatric services

Invests in Prevention, Wellness, Access to Care and Innovation

• Prevention and Public Health Fund

–

$500 million in 2010 and increasing annually up to $2 billion in 2015 for community prevention initiatives

• Community Health Center Expansion

–

$11 billion in funding for the operation, expansion and construction of health centers over the next five years

• Health Workforce Investments

–

Expands primary care workforce

–

Expands National Health Service Corps

• Care Coordination Investments

–

Center for Medicare and Medicaid Innovation (CMMI)

Health Care Reform and Immigrants

Certain immigrant populations are completely excluded from health care reform

 Undocumented individuals are not eligible for coverage

 Medicaid  Health Insurance Exchange  Subsidy

 Legal immigrants continue to face a five year waiting period

for Medicaid

 Some states – including CA -provide coverage to this population

using state dollars but services threatened by budget cuts

 MA court case found that if states cover, comparable services

must be offered

 Exceptions to five year waiting period include people seeking

asylum, refugees and some others

Care Landscape in 2014

Individuals with income up to 138% FPL Eligible for Medicaid based on income alone (Ryan White Program still needed to fill in gaps not covered by Medicaid) Individuals between 138% and 400% FPL Eligible for premium tax credits and cost-sharing subsidies to purchase private insurance (Ryan White Program still needed to fill gaps not covered by private insurance) Individuals with unmet care and treatment needs Ryan White Program still a safety net for: insured people with unmet need and gaps in services legal immigrants not eligible for Medicaid, and undocumented immigrants

M O V I N G TO W A R D H E A LTH CA R E R E F O R M I N A D E F I CI T R E A LI TY

What Is Happening In California?

California at a Crossroads

 Opportunity: California is committed to HCR and

moving ahead

 If health care reform is rescinded CA may be poised to implement

some on its own

 Challenge: CA is moving too quickly and cost/ savings

is one of the top considerations in this economic climate

 Making decisions that are not fully vetted or understood  Assuming immediate savings in programs that aren’t realistic  If federal health care reform is dismantled or defunded,

particularly Medicaid expansion, CA at risk for having to rescind significant advances and actually push people out of care

HIV Care Transitioning to New Systems

 Ryan White programs and support systems created a relatively

seamless system of care

 Both people with HIV and HIV providers will need to transition

to new forms of coverage

 California’s preparation for health care reform

 Low Income Health Programs  Movement into Medi-Cal managed care  Pre-existing Condition Insurance Program

 There is no one agency/ individual “in charge” of this massive

transition

 It involves multiple agencies (previously siloed) working together in new ways

 No effective communications system for providers or clients  No clarity on new systems, and no assistance for individuals,

technical assistance for providers

 Inadequate provider rates, including pharmacy

Low Income Health Programs (LIHPs)

 Medicaid-like expansion established by the Medi-Cal

1115 waiver

 Temporary program will end January 1, 2014

 “Bridge to health care reform” - each individual will

have a transition plan to full Medi-Cal expansion

 Developed, implemented and financed by the county

 Benefits can vary  Eligibility for the program is established by county

Ranges from 25% of Federal Poverty Level (FPL) –

200%FPL*

 Counties are at different stages of LIHP development

Movement to Medi-Cal Managed Care

 All state Medicaids are moving toward managed care

 Two thirds of beneficiaries currently in managed care

 California began moving Seniors and People with

Disabilities in to mandatory managed care in May 2011; complete by July 2012

 Protections for those whose doctors were not

contracted with managed care broke down

 Medical Exemption Request – out of managed care for one

year

 Continuity of Care request – in managed care; continue to see

fee-for-service doctor for up to one year

 Out of county contracting remains unclear

Dual Eligible Coordinated Care Demonstration

 California one of 15 states approved for

demonstration project

 Between 4 and 10 counties, including LA scheduled

for inclusion

 Originally scheduled for January 2013, moved to

March

 Passive enrollment, exception AIDS Health Care

Foundation

 Opt out option for Medicare Managed Care; NOT

Medi-Cal services

 Effectively ends AIDS Home and Community Based Waiver

California Pre-Existing Condition Insurance Pool (PCIP)

 Temporary program ends January, 2014  Eligibility:

 Must be a California resident;  Have no health insurance coverage for the past 6 months

– Ryan White is not considered coverage;

 Be lawfully present in the United States;

 Office of AIDS will pay the premium, drug

deductible ($500), drug co-pay on ADAP drugs

 Will not pay primary care deductible ($1500) or co-pays

 Establishes a cap on out of pocket costs ($2400

annually)

P R I O R I T I E S F O R P E O P L E W I T H H I V

Implementation

• 1. Ensuring a Comprehensive Essential

Health Benefits Package

ACA Essential Health Benefits

• Ambulatory services
• Emergency services
• Hospitalization
• Maternity/ newborn care
• Mental health and substance use

disorder services – to parity

• Prescription drugs
• Rehabilitative and habilitative

services

• Laboratory services
• Preventive and wellness services

and chronic disease management

• Pediatric services

Federal Guidance/ Regulations State Im plem entation Decisions

• Flexibility for most states likely means bare bones

plans

• State variation and disparities will continue
• Continued federal advocacy needed to enforce anti-

discrimination protections

• California:
• Decisions are being made now
• Legislature and Exchange Board are working together
• Benchmark plan: Kaiser small group plan for Exchange
• Medicaid benchmark guidance not complete
• Choices of FEHBP, State Employees, Largest commercial

HMO, Secretary determined equivalent

• Advocates say Medi-Cal plus - administrative burden

much lower

What Does a Benchmark Approach Mean?

• 2. Ensuring Access to Ryan White: Filling

the Gaps

 Essential services needed by people living with

HIV/ AIDS NOT fully covered by EHB:

 Dental services  Case management  Medical case management?  Nutrition services  Transportation  Mental health and substance use services  Peer support services  Insurance assistance

 Medicaid will NOT be available for:

 Undocumented immigrants  Legal immigrants within the 5 year ban

Ryan White HIV/AIDS Program

MA: Post HCR ADAP Costs

• There is no one agency in charge
• State Office of AIDS must work in new ways with

Medicaids and Exchange Boards

• New level of both leadership and collaboration
• Joint stakeholders committee
• Data sharing
• Communication/Education/Outreach/Enrollment
• Although there are funds under ACA for

navigators/assistance – will be essential for RW to cover for people with HIV

• Strategies for screening for movement will need to be in

place

• 3. Ensuring a Safe Transition for

Vulnerable Populations

 Become a Federally Qualified Health Center (FQHC)  Affiliate or integrate w/ a FQHC

 Successful integration in Sonoma County  Careful planning; hired a change specialist and individual

transition coordinator

 98% retention in care rate

 Diversify Funding

 Need as many different types of coverage/ insurance as

possible

• Prepare for an insured client base
• Begin to strategize about when and where Ryan White

must fill gaps

• 4. Preparing for Change in HIV Care

• 5. Making Medicaid Managed Care Work

 Ensure HIV providers are part of the managed care

network and can be identified

 Consider state – specific enhanced reimbursement

strategies

 Consider pharmacy networks as well as medical

providers

 Transition from fee-for-service to managed care

critical

 Clear and effect continuity of care protections are essential

 Medicaid Health Home Program Opportunities

Health Care Reform Planning

“The causes of today’s problems are complex and

• interconnected. There are no simple answers, and

no one individual can possibly know what to do - It is time to stop waiting for someone to save us. We’re all in this together, we all have a voice in how we go forward.” Meg Wheatley

Resources

www.hivhealthreform .org Community based website with California sub- site FamiliesUSA http://www.familiesusa.org/health-reform- central/ Summaries, fact sheets, issue briefs; Join listserv for information updates, including periodic national conference calls on health reform topics Kaiser Family Foundation http://healthreform.kff.org/ Summaries and implementation timeline; Fact sheets on Part D, exchanges and subsidies Treatment Access Expansion Project http://www.taepusa.org/ Analysis of HIV-related provisions, including presentations HealthReform.gov http://www.healthreform.gov/ Administration website with information on the new law, including an ongoing Q&A forum and state-specific information Center for Medicare Advocacy http://www.medicareadvocacy.org/ Policy analysis and beneficiary information

• n the new law’s impact on Medicare,

including Part D