Transcript Document
Federal AIDS Policy Partnership
US Conference on AIDS
September 10, 2013
2006 and 2009 Reauthorizations
Overview of 2009 community consensus process
Overview of changes made in 2009 Ryan White
extension
Ryan White 2013 and beyond
Partners in process
Congress
Administration
Next steps
Very contentious process
All major HIV organizations had own set of
recommendations
House and Senate staff found it very difficult to
work with community and negotiate best possible
bill
Community came to difficult compromises late in
the game
In the end made major changes to Ryan White
Program but also involved significant increases in
funding
$85 million to Ryan White Part B
Community wanted to avoid repeat of 2006
process
Ryan White Work Group
Original Working Group of the Federal AIDS Policy
Partnership (FAPP) (2003)
Coalition of national, local and communitybased service providers and HIV/AIDS
organizations
Consensus/Sign-on Process
Sunset provision meant that action had to be
taken before September 30, 2009
Issue Division:
Implementation fixes needed before extension
Legislative or “technical” fixes
Regulatory fixes
Issues to address in extension
Issues for full reauthorization (2012)
Issues addressed through other processes
1st 100 Days – new Obama Administration
Development of National HIV/AIDS Strategy
Health reform – knew Obama wanted to pass major
overhaul
Consensus Document Agreement
Final document six specific extension requests and
four “technical fixes”
Initial release on March 10, 2009
Technical fixes previously released
323 organizations signed on
Unprecedented level of support
At least one organization signed from almost every
state
Congressional staff were very appreciative to have
one set of recommendations from HIV community
In September 2009, HRSA testified before
Congress and recommended essentially the
same changes made by the community
Biggest difference was four year authorization
period
Consensus document became basis for
legislation introduced by Senator Harkin and
Representative Waxman
Signed into law Oct 30, 2009
Signing ceremony with HIV community leaders
“Ryan White HIV/AIDS Treatment Extension
Act of 2009”
Authorized the program for four years (FY10-FY13)
Removed “sunset” provision allowing program to
remain funded at end of authorization period
Extended hold harmless protections
Extended protection for code-based states during
final transition to name-based HIV reporting
Increased unobligated amounts from 2 to 5 percent
Included ADAP rebate language
Included prevention provisions: EIIHA, 1/3 of Part
A supplemental criteria
Changes to Ryan White Program with FY13
awards
Hold harmless will decrease to 92.5 percent of FY12
award
FY13 funding distributed on names-based cases
reported to CDC. States can no longer report cases
directly to HRSA and 5 percent penalty and cap will
be eliminated.
Ryan White will not see legislative action in
2013
Appropriations/debt ceiling/sequestration
taking up much of legislative days left
Committees have other priority areas that
MUST be worked on
Majority of Ryan White Work Group feels that
not reauthorizing at this point is the best option
for many reasons
Need real information about how ACA will
impact Ryan White clients
Budget/Appropriations environment continues to
be quite constrained and Members looking at all
programs for funds
Other programs currently under consideration for
reauthorization are being given significantly
reduced funding levels
Discretionary health programs continue to be target
for offices not supportive of health reform
Impacts of sequestration and deficit reduction
Less and less appetite in Congress to work on
disease-specific legislation
Ryan White’s authorization will lapse BUT
program will continue to be funded and
implemented
Ryan White Work Group working to educate
Members of Congress and their staff on
importance of Ryan White post-ACA
implementation
Key Congressional Offices
Senate HELP Committee
Tom Harkin (D-IA), Chair
Mike Enzi (R-WY), Ranking Member
House Energy & Commerce Committee
Fred Upton (R-MI), Chair
Henry Waxman (D-CA), Ranking Member
House E&C Health Subcommittee
Joe Pitts (R-PA), Chair
Frank Pallone (D-NJ), Ranking Member
Key staff have had conversations about RW, but no
plans for action at this point
Administration (White House, HHS, HRSA):
The HRSA HIV/AIDS Bureau (HAB) has begun
process to engage community in future of Ryan
White
Federal Register notice and listening session last
summer
HHS Assistant Secretary for Planning & Evaluation
(ASPE) has engaged Mathematica on studies
focusing on health reform and future of Ryan White
Currently conducting Ryan White grantee interviews
Currently meeting monthly to discuss Ryan
White Program and possibilities
Continue to educate Members of Congress
Set-up process to being having conversations
about larger scale reauthorization in 2014 or
when Congress is ready to begin
considerations
Community must be prepared to have
conversations about Ryan White that we have
not had in quite a while:
Part structure
Funding formulas and multiple funding streams
Duplication of services with larger systems of health
care
Specific populations
Many others
SERVICE
QHP
MEDICAID
RX
RW PART B / ADAP
Cost-sharing
assistance
MEDICAL CASE
MANAGEMENT
ORAL HEALTH
LABS
Cost-sharing
assistance
MENTAL HEALTH
SERVICES
Cost-sharing
assistance
SUBSTANCE ABUSE
TREATMENT
Cost-sharing
assistance
HIV PRIMARY CARE
Cost-sharing
assistance
MEDICAL
TRANSPORTATION
INPATIENT HOSPITAL
SERVICES
Limited Coverage
By statute, RWHAP funds may not be used “for any item or service to the
extent that payment has been made, or can reasonably be expected to be
made…” by another payment source
Grantees and their contractors are expected to vigorously pursue enrollment
in other relevant funding sources (e.g., Medicaid, CHIP, Medicare, statefunded HIV/AIDS programs, employer-sponsored health insurance coverage,
and/or other private health insurance)
RWHAP grantees must make every effort to ensure that individual clients
who are not eligible for public programs (Medicaid, CHIP, Medicare, etc.) and
are not exempt from the Affordable Care Act’s requirement to enroll in health
coverage are assessed for eligibility for private health insurance. The RWHAP
will continue to pay for items or services received by individuals who remain
uninsured or underinsured
Recommends grantees align program financial
eligibility determinations with those for new coverage
options, mainly modified adjusted gross income
(MAGI)
Recommends grantees align client recertification
processes with Marketplace eligibility and enrollment
processes to reduce burden and increase coordination
Grantees may consider requiring that clients provide
their Medicaid and/or Marketplace notice of eligibility
determination when applying for or being recertified
for RWHAP
Reiterates that RWHAP grantees must make every effort to
ensure that eligible uninsured clients expeditiously enroll in
private health insurance when possible; this requirement
will be monitored
Grantees need to inform clients of the penalty for not
enrolling
Clients who receive a certificate of exemption from the
Internal Revenue Service (IRS) may continue to receive
RWHAP services
Open enrollment into private health plans is for a limited
time during the year
If the client misses the open enrollment period, the grantee must
make every effort to ensure the client enrolls in the next open
enrollment period
Grantees must maintain policies regarding the required
process for pursuing enrollment for all clients,
documentation of steps to pursue enrollment, and
establishment of monitoring and enforcement of subgrantee processes to ensure enrollment
RWHAP funds may be used to pay for services
received during the time between which a client enrolls
in third party coverage and it becomes effective
Once enrolled in a private health plan, RWHAP funds
may only be used for services not covered or partially
covered by a client’s plan
RWHAP funds generally may NOT be used to pay for
services outside of their insurance network unless
services are not available from an in-network provider
RWHAP funds may be used to pay for higher co-pays
and deductibles within “tiered” networks
Grantees must consider availability of resources prior to
making such allocations
Reiterates that RWHAP grantees must ensure that they vigorously
pursue non-RWHAP funds whenever appropriate for services to
clients before using RWHAP funds, and that eligible clients are
expeditiously enrolled in health care coverage
Requires grantees to evaluate whether paying the cost for health
care premiums or cost-sharing (such as co-pays or deductibles) is
cost-effective and to pay it when grant funds are available
Funds for health insurance premiums and cost-sharing assistance
are considered a core medical service
Funds for health insurance premiums and cost-sharing assistance
must be used to purchase plans that have pharmaceutical benefits
equivalent to the HIV antiretroviral and opportunistic infectionrelated medication on the ADAP formulary and provide coverage
for other essential medical benefits
Grantees who plan to buy insurance should consider providing
funds to the ADAP since many ADAPs have infrastructure to
purchase insurance
Funds may not be used to pay for administrative costs outside of
the premium payment of the health plans or risk pools
Need to consider premium tax credits and cost-sharing reductions
that the individuals may be eligible for when calculating the cost of
purchasing a qualified health plan
Need to document the methodology used to show it is cost-effective
Grantees are encouraged to analyze the formulary, other covered
medical benefits, cost of premium, and cost-sharing reductions
Grantees do not need to select the most cost-effective plan, but the
selected plan must be more cost-effective than if the RWHAP
program were to pay for services and medications
RWHAP grantees and sub-grantees should inform clients regarding
these considerations to assist in enrollment decisions
Align client eligibility
determination with
Marketplace enrollment
periods
Reduce burden by using
MAGI
Collect
Marketplace/Medicaid
notice of eligibility
determination for
annual RWHAP
recertifications
Be able to document
process for pursuing
enrollment
Establish methodology
for conducting
Marketplace costeffectiveness