Transcript Document

Get ready for Oct 1!
An Update, Q&A and Case Discussion Webinar on
Health Care Reform's Impact on HIV Care in the East Bay
September 16, 2013
Kathleen Clanon, MD
Sophy Wong, MD
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At the conclusion of today’s session,
please use the following URL LINK
to complete your participant evaluation form:
http://www.surveymonkey.com/s/N9RM6ZS
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Get ready for Oct 1!
An update, Q&A and Case Discussion Webinar on
Health Care Reform's Impact on HIV Care in the East Bay
September 16, 2013
Kathleen Clanon, MD
Sophy Wong, MD
Objectives
• Apply the information learned to answer basic
questions from patients and colleagues about
Affordable Care Act (ACA) transitions
• Propose 3 important actions to take between now and
December 31st to facilitate continuity of care
• Formulate a plan for addressing problems that arise
after January 1st
National Impact of Health Reform
Reducing the Number of Uninsured
Estimated
32 Million will gain
coverage by 2019
Medicaid:
16 million
Income <133% FPL
Exchange:
26 million
Income 133%400% FPL
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Health Care Reform in California:
The Low Income Health Program
• Under the Bridge to Reform 1115 Federal waiver, California has been
making preparatory steps to HCR since 2011.
• This waiver program, known as the Low Income Health Program or LIHP,
has two parts:
– Medicaid Coverage Expansion (MCE) for those with income < 133% of FPL
– Health Care Coverage Initiative (HCCI) for those with income 133.01%-200% of FPL
• Open only to adults who are citizens or legal permanent residents (LPRs)
living in the U.S. for more than 5 years
• Statewide, more than 600,000 previously uninsured people have enrolled
in LIHP
Health Care Reform in Alameda County:
HealthPAC
•
Alameda County’s waiver or LIHP is
called HealthPAC which includes
MCE, HCCI, and HealthPAC County
•
“HealthPAC County” represents
those not eligible for MCI or HCCI.
– HealthPAC County will continue
after 1/1/14 primarily with
County funding.
•
Sept 2013 Enrollment includes
– MCE 42,022 members
– HCCI 6,941 members
– HPCounty 40,946
HealthPAC
MCE
43k Medi-Cal
HealthPAC
County
41k  stay same
HealthPAC HCCI
7k  Covered CA or
Medi-Cal
Sister Counties
• Contra Costa
• Solano
PWHIV in the LIHP
Alameda County
• Not comprehensive; no way
to identify people by
diagnosis
• These data come from
prescribing info
• Does not include Kaiser
patients
• Many PWHIV already on
Medi-Cal
Alameda County HealthPAC Enrollee Transitions
2013-2014
Transition Mechanics: MediCal
• Enrollees from the MCE program will be automatically
enrolled as Medi-Cal beneficiaries.
• No action is required on their part for them to continue as our patients.
• Mailed notices in threshold languages will go out to these enrollees from
the State and County beginning in October, letting them know they have a
right to chose a Managed Care Plan (Alliance or Anthem/Blue Cross in
Alameda County)
• The notices will specifically state that, if enrollees are happy with their
provider, they need not take any action
• The State DHCS will provide a comparison of the MCPs (Managed Care Plans)
in each region in October, including a focus on issues relevant to PWHIV
Plan Formulary Comparisons:
Alameda County
AAH/HPAC Crosswalk Summary
•
•
17 unique drugs not covered
40% of the covered drugs require PA or other utilization mgmt criteria (ie: step therapy,
quantity/fill limits, gender/age edits)
•
Anthem Blue Cross/HAPAC Crosswalk Summary
•
•
2 unique drugs not covered
3% of the covered drugs require PA or Step Therapy
Rules are described in W&I Code sec# 14185:
•
•
Requires pharmacies to dispense 72 hours meds
May require 30 days worth of meds covered if they were covered under LIHP – State DHCS is
clarifying
Transition Mechanics: Covered California
• LIHP will upload list of Exchange
Eligibles to Covered California
• Open enrollment begins 10/1/13,
ends 3/31/14
• Enrollees MUST apply to be
covered
• Covered CA will reach out by mail
and phone to all eligible LIHP
enrollees
Timeline of Notices to EnrolleesCA state will send to MCE patients:
Sept 2013
 general notice
Nov 2013
Dec 2013
 plan choice notice
 plan choice reminder
 call/email DHCS
with plan choice
 call/email DHCS with
plan choice if not done
Mid-Dec 2013
January 14, 2014
 Medi-Cal welcome packet
 Managed care plan
welcome packet and benefit
card
 Beneficiary Identification Card (BIC)
Timeline of Notices to Enrollees:
sample transition letter
Timeline of Notices to EnrolleesCovered CA will contact HCCI patients:
Sept 2013
 Covered CA notice
Oct-Nov 2013
 outreach phone call
 enroll in Covered
CA by March 2014
“Residually Uninsured”
Not Covered Under HCR
• Care for those enrolled in HealthPAC county will remain
the responsibility of the County
• It is likely that many Exchange eligibles will also choose
not to enroll in a plan; their care will also be covered by
the County, with associated charges to ensure it is not
a more attractive option than joining the Exchange
• This group will remain eligible for care and drug
coverage under Ryan White
Reduction in Uninsured as a Result of HCR
Alameda County
HealthPAC Enrollees
100,000
90,000
Reduction of
80,000
Number of Enrollees
70,000
43,000
51% in # of
uninsured
individuals
60,000
50,000
7,000
HealthPAC MCE
HealthPAC HCCI
3,500
HealthPAC County
40,000
30,000
20,000
42,000
42,000
2013
2014
10,000
-
49%
Funding for Uninsured After HCR Implementation
Alameda County
HealthPAC Funding
$160,000,000
$140,000,000
Reduction of
$120,000,000
$49,300,000
$100,000,000
funding
$80,000,000
$60,000,000
58% in
1991 Realignment
HCSA Measure A
$40,000,000
$-
Federal
General Fund
$42,200,000
$6,000,000
$7,000,000
$20,000,000
Restricted Medi-Cal
$38,400,000
$39,100,000
$5,500,000
$5,000,000
2012-2013
2014-2015
Transition Issues for PWHIV
• Open referrals
• Receiving Beneficiary ID Cards (BIC’s)
• Intersection with Ryan White
Covered in case discussion:
• Pharmacy and formulary issues
• Provider assignment
• Covered California enrollment
Preparing your site…
Questions?
Case #1: Pharmageddon
Joe is an HPAC-MCE client with HIV. It is January 6, 2014, and Joe has not
opened any mailings from Medi-Cal. He has one dose of Atripla left and is
completely out of antidepressants and pain meds. He goes to his usual
pharmacy, where they are unable to bill his ARV to HPAC HIV Program thru
Ramsell as they have done monthly since August 2012, but are able
(inappropriately) to bill the antidepressant and Vicodin to Joe’s medical
home.
1.
2.
3.
4.
What will Joe likely do?
What could be done by Joe’s providers to prevent or mitigate this?
Who at Joe’s provider should be ready to field these questions?
How will the pharmacy know the client’s new managed care plan
(AAH or Anthem Blue Cross)?
Case #2: Wrong Provider Assignment
Yvette is an HPAC-MCE enrollee seen for years at EBAC. She is
auto-assigned to Anthem/Blue Cross and to a provider near her
home. She brings her BIC to her appointment and, in the
financial screening before her visit, is informed she is no longer a
patient at EBAC.
1. What could be done by Yvette’s provider to prevent this?
2. Who at your site will likely see these problems come to them?
3. What should be done to resolve the question?
Case #3a: (Un)Covered California
Joaquin is a 26 year old waiter. He has been seen at Highland for
his HIV and is an HPAC HCCI enrollee. He has some information
that he should sign up for insurance, but doesn’t know how. It is
January 15th and he comes in for a routine visit. In financial
screening, he is told HPAC is gone and he needs now to pick a
Covered California plan. He is reluctant to talk to the assistors
even on the phone because of his HIV.
1. What could his provider do to prevent or mitigate this?
2. How can we help clients with HIV weigh Covered California
plan options?
Case #3b: Joaquin in April 2014
Now it’s April 2014, and Joaquin never managed to sign up for a
plan.
He comes in for care.
1. How will his care be covered?
2. How about his medications?
Questions?
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East Bay
AIDS Education & Training Center
Sophy Wong, MD, Medical Director
Shailey Merchant Klinedinst, MPH, Program Manager
Gracie Askew, Training Coordinator
(510) 835-3700 phone
(510) 625-9307 fax
www.eastbayaetc.org
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Please use the following URL to complete your participant
evaluation form:
http://www.surveymonkey.com/s/N9RM6ZS
We will also email the link directly to you as well.
Thanks!
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