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HIV Care Under the Affordable Care Act Addressing the Needs of HIV Clinics and Clinicians in Pennsylvania May 2015 Julia Hidalgo, ScD, MSW, MPH Research Professor, George Washington University and CEO, Positive Outcomes, Inc. [email protected] Today We Will Address Key provisions of the Patient Protection and Affordable Care Act (ACA) Federal and State Medicaid policies provider participation and covered benefit provisions Eligibility, service delivery, and payment systems Focus on challenges and opportunities for Pennsylvania HIV clinical, social support, and prevention providers Maximizing third party reimbursement for HIV prevention, care, and support services through collaborative strategies ACA Marketplace From: Hidalgo J and Edelbrock E. Commercial Health Insurance Basics for HIV Prevention Programs Webinar. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-3-commercial-health-insurance-basics-for-hiv-prevention-programs/ ACA Requirements: Essential Health Benefits (EHBs) Ambulatory patient services Hospitalization Emergency services Pregnancy, maternity, newborn care, and pediatric services (oral and vision care) Mental health and substance abuse disorder services (i.e., behavioral health treatment) Prescription drugs Rehab and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management ACA Requirements: Essential Community Providers (ECPs) ECP Category ECP provider Type Federally Qualified Health Centers (FQHCs) FQHCs and other community health centers, and healthcare facilities operated by Indian tribes and other Indian organizations RWHAP provider Ryan White HIV/AIDS Program-funded providers Family Planning provider Title X family planning clinics and look alike family planning clinics Indian Health provider Indian Health Service (IHS) providers, Indian tribes organizations, and urban organizations Hospital Disproportionate share hospitals (DSH) and eligible hospitals, children’s hospitals, sole community hospitals, and other similar facilities Other ECP providers STD clinics, TB clinics, and other entities that serve predominantly low-income, medically underserved individuals ACA Requirements: ECPs CMS issued a letter to Federally-Facilitated Marketplaces in December 2014 QHPs must contract with at least 30% of ECPs in each QHP’s service area Offer contracts in good faith to all available Indian health providers in the service area Offer contracts in good faith to at least one ECP in each ECP category in each county in the service area Where an ECP in that category is available and provides medical or dental services that are covered by the issuer plan type (i.e., Individual or SHOP) To be in “good faith,” a contract should offer terms that a willing, similarlysituated, non-ECP provider would accept or has accepted Issuers must be able to provide verification of such offers if CMS chooses to review the offers for compliance ACA Requirements: Preventive Services DHHS US Preventive Services Task Force (USPSTF) recommends “A” grade for HIV infection screening Adolescents and adults ages 15 - 65 years Younger adolescents and older adults at increased risk All pregnant women, including those presenting in labor who are untested and whose HIV status is unknown “A” grade for syphilis for all pregnant women and other persons at increased risk for infection “B” grade for chlamydia screening for sexually active women age 24 or younger and in older women at increased risk for infection “B” grade for STD counseling for sexually active adolescents and for adults at increased risk for STDs ACA QHPs in PA Offering Coverage on the Federally Facilitated Marketplace (FFM) QHPs Aetna Assurant Health Blue Cross of Northeastern Pennsylvania| Capital BlueCross Coventry Geisinger Choice Geisinger Health Plan Highmark| Highmark Health Insurance Company| Independence Blue Cross Keystone Health Plan Central, A Capital BlueCross Company UnitedHealthcare UPMC Health Plan Aetna acquired Coventry | Highmark acquired BC of NE PA, will continue to operate as an Anthem BCBS franchise Individual SHOP Impact of the ACA on State Medicaid Programs From: Hidalgo J and Edelbrock E. Medicaid Basics for HIV Prevention Program. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-2-medicaid-basics-for-hiv-prevention-programs/ Medicaid Overview Federal and state entitlement program Medical assistance for people with limited income and resources Covers 60 million adults and children Enrollment in “traditional” Medicaid is commonly via TANF, Aged, Blind, Disabled or other Categorical Programs Supplements Medicare benefits for 9 million low income aged and/or disabled individuals Disability continues to be a common pathway to Medicaid and Medicare for HIV+ adults Beginning in 2014, the ACA permitted states to expand Medicaid optionally to non-disabled individuals Anyone who is poor (include < $16,104 or 138% of the FPL) 4.8 million Americans enrolled in expanded Medicaid Until ACA Medicaid expansion implementation, PA HIV+ adults commonly enrolled in Medicaid through enrollment in Social Security Administration (SSA) disability or TANF benefits. In PA, applications for SSA disability benefits are determined by the PA Bureau of Disability Determination Average Monthly SSA Initial SSI Allowance Rates in GA, LA, PA, TX, WA, By Year, 2001 to 2014 60.0 50.0 40.0 30.0 20.0 10.0 0.0 2001 2002 2003 2004 2005 GA 2006 LA 2007 PA 2008 TX 2009 WA 2010 Linear (PA) 2011 2012 2013 2014 ACA-Related Medicaid Benefits EXPANSION STATES ACA requires adults enrolling through Medicaid expansion must receive “alternative benefit plans” (ABPs) Must include the ten “essential health benefits” (EHBs) required for Marketplace QHPs Must provide the full range of prevention services, including preventive services rated “A” or “B” by the USPSTF at no cost to beneficiaries Must cover family planning services and supplies (e.g., condoms), parity between physical health and behavioral health services, nonemergency transportation, and FQHC and Rural Health Center services New Opportunities for Medicaid Payment for Preventive Services CMS published a final rule effective in January 2014 Before the rule change: preventive services could only be provided by a physician or other licensed practitioner (OLPs) of the healing arts to be paid by Medicaid After the rule change: other practitioners, not just physicians and OLPs, can be paid to provide preventive services recommended by a physician or OLP Assigns authority to State Medicaid Programs to Define practitioner qualifications Ensure appropriate services are provided by qualified practitioners Define the preventive services to be provided Design the reimbursement methods Does not define the type of personnel to be covered PA HealthChoices Managed Care Organizations Zones HealthChoices MCOs Aetna Better Health AmeriHealth Caritas PA Lehigh/ Cap SE SW Keystone First UnitedHealthcare Community Plan UPMC Health Plan, Inc. New West AmeriHealth NE Gateway Health Geisinger Health Plan (Geisinger Family) Health Partners Plan New East PA HealthChoices MCO Contract Provisions and Other HIV Benefits MCO member handbooks must include information about HIV/AIDS programs and how to access them Family planning clinic visits cover HIV-I and HIV-II antibody testing DPW Office of MA Programs HealthChoices Adult HIV Clinical Practice Guidance references the NIH treatment and prevention guidelines but does not specify MCO requirements MCOs must staff Special Need Units (SNUs) Targeted Case Management Program FFS Intense Medical Case Management for beneficiaries with symptomatic HIV or AIDS AIDS Home and Community-Based (HCBS) Waiver PA HealthChoices MCO SNU Required Activities Serve members with special needs, including HIV/AIDS Develop an appropriate automated process to operationalize information on members with special needs supplied by the enrollment contractor Develop adequate provider networks to serve special needs populations Provide ongoing coordination with PCPs to serve members with special needs Assist and support members in making an informed choice between providers of equivalent services within the network When adequate network capacity does not exist to allow for choice between network providers of equivalent services, facilitate and coordinate services rendered by out-ofnetwork providers Coordinate between the MCO and other health, education, and human services systems Facilitate communication and coordinate service delivery between primary care, specialty, ancillary, and behavioral health providers to ensure member's timely and uninterrupted access to care PA HealthChoices MCO SNU Required Activities Establish sufficient telephone and alternative communication channels to allow ready and timely interactions with members, their providers (network and out-of-network), and involved agencies Arrange to assist members who speak languages other than English, and match members with providers to address barriers due to disability or linguistic background Train MCO staff to acquaint them with the SNU and the need to coordinate within departments to serve members Conduct necessary training for PCPs to help them to provide services to diverse populations Have a working knowledge of principles and principles of drug and alcohol treatment Report and, when appropriate, develop plans of correction for quality indicators including access to the SNU, PCPs, specialists, and ancillary services Develop and maintain targeted QM focused on members with special needs PA 1115 Demonstration Waiver to Expand Medicaid Eligiblity Overview: Covers Duration: about 500,000 newly eligible adults ages 21-64 statewide via private Medicaid MCOs Premiums for all newly eligible and some currently eligible beneficiaries > 100% FPL beginning in Year 2. Beneficiaries can have premiums or cost-sharing reduced by complying with specified healthy behaviors. 1/1/15 to 12/31/19 Covered Populations INDIVIDUALS COVERED • Ages 21 - 64 eligible in the new adult group under the State Plan • Women who become pregnant can elect to remain enrolled in their MCO • Beneficiaries who lose eligibility under Section 1931 due to spousal support • Employed: 12-month continued assistance due to increased earnings or work hours • Receiving HCBS: Special income level group, with gross income that does < 301% of the SSI income standard; receives long term services and community supports INDIVIDUALS NOT COVERED • Medically frail as determined by approved Alternative Benefit State Plan provisions • Pregnant women, except those who become pregnant and elect to stay enrolled • Institutionalized beneficiaries • Dual Medicaid and Medicare eligibles (remain in Healthy Horizons Program) • Beneficiaries < 21 or > 65 years of age and older Premiums for individuals < 100% FPL Yes No Yes Yes Yes, unless otherwise exempt NA PA 1115 Demonstration Waiver to Expand Medicaid Eligiblity Element Pennsylvania Waiver Provisions Demonstration Improve access to care and health outcomes through private coverage options; improve health Goals: outcomes and lower overall costs through incentives to obtain preventive services and engage in healthy behaviors; and affect utilization and increase use of preventive services and beneficiary satisfaction through premiums in lieu of cost-sharing for beneficiaries over 100% FPL. Premiums: Beginning in Year 2, the State may charge monthly premiums up to 2% of household income for newly eligible adults > 100% FPL and certain currently eligible beneficiaries > 100% FPL 90 day grace period before disenrollment for failure to pay premiums. After 90 days, unpaid premiums may be considered a collectible debt owed to the State. Beneficiaries may re-enroll without a waiting period. Delivery Medicaid benefits will be provided through private MCOs. Plan contracts must comply with Systems and existing federal Medicaid managed care rules. Benefits: Benefits package for current and newly eligible beneficiaries will be pursuant to State Plan amendments to be submitted. Waiver of non-emergency medical transportation for all newly eligible adults in Year 1. The State will provide non-emergency medical transportation to these beneficiaries beginning in Year 2. In Year 1, the State shall undertake efforts to ensure that newly eligible adults will have the ability to use non-emergency medical transportation by Year 2 and shall provide a readiness plan to CMS by March 31, 2015. PA 1115 Demonstration Waiver to Expand Medicaid Eligiblity Element Pennsylvania Waiver Provisions CoAll demonstration beneficiaries will pay State plan co-pays in Year 1 Payments: In Year 2, beneficiaries subject to monthly premiums only have co-pays for non-emergency use of the ER ($8 per State Plan amount). Cost at State Plan amounts will continue for beneficiaries < 100% FPL. Beginning in 1/2016, State may collect and analyze data regarding average monthly copays for beneficiaries < 100% FPL and submit a waiver amendment seeking a premium model for this group All cost-sharing (including premiums and co-pays) is limited to 5% of household income State must submit a premium and co-pay monitoring protocol by August 31, 2015 Healthy Beginning in Year 2, beneficiaries can reduce their premiums or co-pays by completing Behavior healthy behaviors in the prior year. Beneficiaries must complete an annual wellness exam Incentives: and make timely co-pays in Year 1 to qualify for decreased premiums or co-pays. After Year 1, eligibility for premium or co-pay reductions based on healthy behavior activities will be evaluated every 6 months. State must submit for CMS approval annually a protocol for healthy behavior activities. Year 1 protocol is due March 31, 2015, and then on August 31 in subsequent years. Opportunities for HIV Core Medical, Support, and Prevention providers in the ACA and Medicaid Reform Addressing Health Insurers’ Interests Via Services Offered by HIV providers Health Insurers’ Interests Services That HIV providers Might Offer Identify enrolled members that do not obtain preventive or other services Essential covered benefits Outreach, linkage, patient navigation Address members’ healthcare and health insurance literacy needs Prevent communicable diseases including HIV, STDs, TB, and HCV Non-MCM, patient navigation, health education nPEP and PrEP support, HIV/STD CTS, behavioral prevention, condom distribution and education, HERR Translation and health education RWHAP core medical providers Address members’ linguistic and numeracy needs to ensure that they can participate actively in health promotion, prevention, and care Culturally competent care coordination, disease Culturally competent workers with management, treatment education expertise in serving racial, ethnic, and sexual minority populations Addressing Health Insurers’ Interests Via Services Offered by HIV providers Services That HIV providers Might Offer Ensure access to physical, behavioral, and other MCM, navigation, behavioral health outpatient services to promote health, and tx support, medical transportation prevent and treat disease Ensure HIV+ clients receive and optimally MCM, navigation, tx education and benefit from ARVs and other medications adherence counseling, MCM Coordinate services provided by the care team MCM with the client, his/her family, and community resources Disease management MCM Discharge planning and readmission prevention MCM interventions for hospitalized patients Health Insurers’ Interests Align With Your Organization Before Seeking New Opportunities Before moving forward, it is critical to Ensure your HIV program’s efforts are aligned with your organization’s overarching readiness efforts An important step for HIV practices in large integrated health systems, hospital-based or university-affiliated health systems, local health departments, large FQHCs Contracts may have been negotiated or are being negotiated QHP and Medicaid MCO contracts have probably been finalized for the current year Engage organizational leadership, including corporate board support Identify organizational resources that can be applied to your contracting and collaboration activities Resources for Contracting for HIV Prevention and Care Services HealthHIV. Health Insurance Contracting for HIV Prevention and Wrap-around Service providers. 2015. Available at: http://wwwhealthhiv.org HIV Medicine Association. Strategies for HIV Medical providers Contracting With Health Insurers. 2013. Available at: http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advoca cy/Policy_Priorities/Healthcare_Reform_Implementation/Resour ces/Strategies%20for%20HIV%20Medical%20providers.pdf On Our Own Virtual Integration Physical Integration Acquisitions & Mergers • Chart your own organizational course • Enhance your TPR capacity, join insurers’ FFS programs and networks • Crush the competition • Adopt a “trade association” model • Collaborate in information gathering, purchasing, and marketing • ASOs seek out and create formal relationships with HIV clinics, community health centers, or other core providers • Co-locate services but remain independent organizations • Share infrastructure costs • Identify agencies with services strengthening your capacity and “buy them” • Identify similar agencies but different service areas or populations and merge • Transfer clients to a fiscally solvent, culturally competent, and high quality agency close HIV program Collaborative Integration Strategies QHP or MCO Contract for services using “grant” type budget, FFS, sub-capitated arrangements Augment care management services provided by the insurer through contract Contract with provider networks to provide HIV and HIV services Hospital Provide subcontracted essential and other covered services Systems Coordinate and collaborate to serve HIV+ and non-HIV+ clients Subcontract with CBOs and handle their billing FQHCs & HIV Clinics CBOs Provide subcontracted essential and other covered services Coordinate and collaborate to serve HIV+ and non-HIV+ clients Subcontract with CBOs and handle their billing Provide subcontracted outreach, HIV and STD testing, linkage, home visits, MCM, preventive services How to Learn More About ACA and MedicaidRelated Health Insurers in My State